Fast Facts Dermatological Nursing

Edited by Rebecca Penzer-Hick

Dermatological Nursing

This educational resource has been sponsored by Bristol Myers Squibb. Bristol Myers Squibb has had no input into the content or control over the delivery of this material.

This book has been sponsored and funded by Eli Lilly and Company. Eli Lilly has had no input into the content of this material.

This book has been sponsored and funded by Novartis Pharmaceuticals UK Ltd. Novartis has had no input into the content of this material.

Fast Facts for Healthcare Professionals

Dermatological Nursing

A practical guide on career pathways

Edited by Rebecca Penzer-Hick

President, British Dermatological Nursing Group

Senior Clinical Lecturer, University of Hertfordshire

Dermatology Specialist Nurse

Dermatology Community Clinic Services, Buckden, UK

Sarah Copperwheat,1 Lucy Moorhead,2 Saskia Reeken,3 Melanie Sutherland,4 Julia Wheeler,5 Carrie Wingfield,6 Heulwen Wyatt7

1Community Dermatology Nurse, Central and North West London NHS Foundation Trust, Milton Keynes

2Nurse Consultant in Inflammatory Skin Disease, St John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust, London

3Nurse Consultant in Skin Cancer and Dermatology, Kingston Hospital NHS Foundation Trust, London

4Dermatology Nurse Registrar – Inflammatory Diseases with a specialist interest in lower limb conditions, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk

5Dermatology Lead Outreach Nurse, Buckinghamshire Healthcare NHS Trust, Aylesbury

6Nurse Consultant in Dermatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk

7Clinical Nurse Specialist, Paediatric Dermatology, St Woolos Hospital, Newport

Declaration of Independence

This book is as balanced and practical as we can make it.

Ideas for improvement are always welcome: fastfacts@karger.com

Fast Facts: Dermatological Nursing

First published 2023

Text © 2023 Rebecca Penzer-Hick

© 2023 in this edition S. Karger Publishers Ltd

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ISBN 978-3-318-07135-1

Penzer-Hick R. (Rebecca)

Fast Facts: Dermatological Nursing/ Rebecca Penzer-Hick

Cover photograph courtesy of Lucy Moorhead rn ma, Guy’s and St Thomas’ NHS Foundation Trust, London.

Typesetting by Amnet, Chennai, India. Printed in the UK with Xpedient Print.

List of abbreviations

ABPI: ankle brachial pressure index

ACD: allergic contact dermatitis

AfC: Agenda for Change

BAD: British Association of Dermatologists

BDNG: British Dermatological Nursing Group

CNS: clinical nurse specialist

DLQI: Dermatology Life Quality Index

DOPS: direct observation of procedural skills

EASI: Eczema Area and Severity Index

elfh: elearning for healthcare

GAD: Generalised Anxiety Disorder (assessment)

GIRFT: Getting It Right First Time (national dermatology report)

HNA: holistic needs assessment

MDT: multidisciplinary team

MED: minimal erythema dose

NICE: National Institute for Health and Care Excellence

OSCE: objective structured clinical examination

PASI: Psoriasis Area and Severity Index

PHQ: Patient Health Questionnaire

POEM: Patient-Oriented Eczema Measure

PUVA: psoralen and UVA light (photochemotherapy)

SCC: squamous cell carcinoma

SOP: standard operating procedures

UVA/B: ultraviolet A/B (light)

Introduction

Providing dermatology care to the large number of people with skin disease requires a workforce that is appropriately trained and competent to meet patients’ needs safely and effectively. Nurses form a critical part of the team that provides that care and they are increasingly developing new skills and approaches that complement the skills of the other healthcare professionals they work with.

Here, we aim to provide practical guidance for developing these more advanced roles, with signposting to additional resources.

It should be noted that the roles and responsibilities outlined throughout this resource will vary according to service needs in different regions and places of work, and should be seen as a guide rather than definitive job descriptions.

As well as detailing the competences that must be demonstrated by individual nurses moving into new roles, this concise resource considers the organisational responsibility required to ensure that these more advanced roles are undertaken against a backdrop of effective clinical governance.

After reading this Fast Facts resource, dermatology nurses will:

• be aware of a variety of career pathways in subspecialist dermatology fields

• have a clear understanding of the clinical skills required in these areas

• know how to proceed with their training.

Dermatology offers many exciting career pathways in which nurses can fully utilise their nursing skills. We hope that this will be a valuable resource for any dermatology nurse looking to develop their career.

Dermatological conditions affect all ages, races, ethnicities, sexes and genders. This means that the dermatology nurse needs multifaceted skills to manage both the physical and mental sequelae of skin conditions, along with a deep empathy for what it means to live with skin that can feel profoundly uncomfortable both physically and psychologically. Whether it is a child with eczema or an elderly man with skin cancer, dermatology nurses must be knowledgeable about therapeutic interventions and able to provide psychological care to support mental health wellbeing.

The challenges posed by the needs of such a diverse patient group are, in part, what makes dermatological nursing such an interesting and satisfying specialty to work in. This book aims to outline the many and varied possibilities open to nurses who join this specialty. For those who are already working in dermatology, it will provide a guide to help with career development, providing insights into key aspects of dermatological nursing with suggestions for developing new skills and knowledge.

The state of dermatological nursing in 2022

In many respects, dermatological nursing is currently in a strong and vibrant position. There are numerous possibilities for role development: the British Dermatological Nursing Group (BDNG) has more members than ever and the number of opportunities for education and research continue to grow.

However, there are also unprecedented challenges. Before the coronavirus (COVID-19) pandemic the specialty was struggling with workforce issues and an increased demand for its services. The GIRFT (Getting It Right First Time) national report on dermatology, published in 2021, highlighted some of the challenges, including shortages of consultant dermatologists, a significant increase in the number of patients with suspected skin cancers, greater access to new drugs meaning more people who could be successfully treated and, in general, a higher expectation from the public to resolve their dermatological issues.1 On top of these challenges have come the huge pressures of managing the consequences of the pandemic.

In this book, dermatology nurses write about how they continue to provide excellent care for patients with skin conditions despite these challenges, nurses who have worked with other members of the

multidisciplinary team (MDT) to find new ways to meet the needs of patients.

Dermatology nurses, regardless of their band, have an incredibly important role in making sure that patients with skin disease access the right care, at the right time and in the right place. As the opportunities for developing new roles in dermatological nursing increase, there needs to be an ongoing push to encourage more nurses to join the specialty.

The patient care setting

Dermatological nursing is predominantly an outpatient specialty, which means that most patient care is undertaken in outpatient departments of hospitals. However, dermatology nurses also work as part of specialist services in community settings, private healthcare, aesthetics and the pharmaceutical industry. There are very few dedicated dermatology inpatient facilities; patients with serious skin disease who require hospital care are usually looked after on a general medical ward. Some hospitals have a liaison nurse who ensures that patients with dermatological conditions on general wards receive the appropriate care.

What skills does a dermatology nurse need to have?

Dermatological nursing rarely requires the delivery of acute care. Most conditions are chronic in nature and therefore of utmost importance is the ability to work alongside patients to find the best therapeutic options for them and to help to optimise their safe and effective use. This includes treatments for patients with inflammatory dermatoses and skin cancer. Excellent communication skills are paramount to facilitate psychological support, adherence to treatment and patient education. Developing more advanced communication skills, for example motivational interviewing or health coaching, are ways of enhancing the care offered to patients.

Specialising within dermatological nursing. When nurses first join a dermatology team it is beneficial for them to gain broad experience of the many different facets of dermatological nursing, undertaking supervised roles in phototherapy, patch testing, leg ulcers, general dermatology clinics and skin surgery. This allows a broad

understanding of the roles available and provides experience of all the possible patient journeys within a dermatology service. Specialising in one or two of the above areas usually happens at the higher band levels, where independent practice and decision-making require depth rather than breadth of knowledge.

There are many opportunities for independent practice within dermatological nursing. As this book will demonstrate, nurses can remain in clinical care to the higher band levels – up to band 8c –and the breadth of clinical subspecialisation within dermatological nursing is wide, with opportunities for nurses to develop skills that best suit their temperament and interests.

As well as clinical care, dermatology nurses practise in research and education and take on leadership roles. Research may be at the level of data collection and patient recruitment for clinical trials, or it may be as a principal investigator leading teams of researchers on bespoke projects. Educational roles can involve delivering local teaching and training within a department, delivering a paper at a conference or working with a higher education institute up to Masters level. Many dermatology nurses use their excellent leadership skills to head up teams and develop project ideas that transform practice.

Whatever your interest, dermatological nursing can provide the relevant opportunities.

BDNG role descriptors. This book makes regular reference to BDNG role descriptors, which, published in association with the British Association of Dermatologists (BAD) in 2020, aim to describe the scope of practice for dermatology nurses from band 5 to band 8.2 These descriptors use Health Education England’s four pillars of practice as a framework: clinical practice, leadership, education and research.3 (While developing the role descriptors, reference was also made to the relevant equivalent documents in other countries of the UK.) Given the clinical focus of the Fast Facts book series, this title focuses on the development of clinical skills rather than the other three pillars. However, as you think about how your career might progress it is important to also consider developing skills in leadership, education and research.

Table 1.1 gives ideas for the kind of educational input nurses will find useful when progressing from band 5 to band 8.

training and development strategies for career progression

7 to Band 8

In-house skills training (on the job)

BAD conference

International confer ences

NHS leadership academy training

6 to Band 7

In-house skills training (on the job)

Specialised clinical courses

Formal MSc study in advanced practice or dermatology MSc

Independent prescribers’ training

conference

On-the-job improvement pr oject

Masters-level education module in leadership

Participate in an external gr oup/ committee

Governance and safety

of roleBand 5 to Band 6

Clinical• In-house skills training (on the job)

Competency frameworks

BDNG online resour ces

Specific clinical training modules

Topic-specific study days via BDNG/BAD/sponsor ed events

BDNG ambassador programme

Leadership•

Audit training

NHS/in-house leadership development programme

Become a link nurse or team lead for a specific area of practice (e.g. infection contr ol)

Terms used

Several terms, detailed below, are frequently referred to throughout this resource.

Scope of practice. To ensure that nurses practise safely and lawfully they should always work within their scope of practice. Scope of practice is defined as an individual’s limits of knowledge and skill set that determine the activities undertaken within their nursing role. Your scope of practice should always reflect the standards set by the Nursing and Midwifery Council in its code of professional practice.4 The BDNG role descriptors describe the scope of practice that is relevant for each band within dermatological nursing.2

Protocols. A protocol usually relates to a specific area of practice or group of patients and is an agreed framework that covers the care that group of patients can expect to receive. Protocols should outline the lines of accountability and should always fit with professional guidance. A protocol should make clear why, when, where and by whom the care is given.

Competence defines the ability of a nurse to deliver care reliably and safely. Competency frameworks break down how each task should be performed into constituent parts that make up the competence needed for safe practice. Competency frameworks may also include knowledge-based competences, which demonstrate the underpinning knowledge required to practise safely. Competences can be measured in several ways to determine the level of competence at a given point in time: for example, an objective structured clinical examination (OSCE). Table 1.2 shows the levels of competence used by the BDNG. In most instances competence must be demonstrated a number of times across different domains. Specific competency frameworks are provided in some of the following chapters.

Who to talk to

In the following chapters, each of the authors offers suggestions as to how to develop skills that will facilitate the development of your career in dermatological nursing. Speaking to others within the profession features highly in their recommendations and a good

Levels of competence

LevelCompetency

0

1

2

3

4

5

Cannot perform this activity in the clinical environment but knows the key principles involved

Can perform this activity with constant supervision and some assistance

Can perform this activity with some supervision and assistance

Can perform this activity satisfactorily without supervision or assistance

Can perform this activity satisfactorily with more than acceptable speed and quality of work

Can perform this activity satisfactorily with more than acceptable speed and quality of work and with initiative and adaptability to special problem situations

place to start is the BDNG, which can provide direction with regards to educational opportunities and people in your local area who can be contacted for further advice. Joining the BDNG will give you access to all its educational resources, including the quarterly journal

Dermatological Nursing. Many employers advertise jobs through the BDNG, and these are highlighted in regular bulletins to members. Complete novices to dermatological nursing will benefit from contacting their local dermatology unit to see if there are any job opportunities or to see if an informal visit is possible. Dermatological nursing is a small profession but the nurses who work in it are passionate about their specialty and are usually delighted to talk to others about it, encouraging them to join the specialty.

Personal reflection

My career in dermatology nursing has been hugely rewarding. As the brain and the skin are so intimately connected, supporting people with skin disease means understanding and looking after both the psychological and physical impacts.

Key points – succeeding as a dermatology nurse

• Dermatological nursing offers significant scope for developing nursing practice.

• Dermatological nursing usually involves non-acute care skills, but there is significant diversity of opportunity in terms of scope of practice, from skin surgery to chronic disease management to paediatric dermatology.

• Specific technical skills are needed alongside the more generic abilities of excellent communication skills and empathy for the effects that skin disease can have on patients’ quality of life and mental health wellbeing.

• Af ter gaining some general experience in dermatology, specialising in one or two particular areas allows nurses to develop greater levels of independent autonomous practice.

• Contacting others in the specialty and developing professional networks will help facilitate individual career development as well as contributing to the overall development of the specialty.

References and resources

1. Levell N. Dermatology. GIRFT P rogramme National Specialty Report. NHS Publishing, 2021. www.bad.org.uk/gettingit-right-first-time-girftdermatology-report-launches, last accessed 1 February 2022.

2. Br itish 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/wpcontent/uploads/2020/08/ BAD-BDNG-RCN-NURSINGWORKSTREAM-A4LANDSCAPE-002.pdf, last accessed 1 February 2022.

3. NH S England. Multi-Professional Framework for Advanced Clinical Practice in England. NHS England, 2017. www.hee.nhs.uk/sites/default/ files/documents/multi-profes sionalframeworkforadvanced clinicalpracticeinengland.pdf, last accessed 1 February 2022.

4. Nu rsing and Midwifery Council. The Code. Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. Nursing and Midwifery Council, 2015. www.nmc.org.uk/code, last accessed 1 February 2022.

Wheeler

Holistic assessment

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

Validated assessment tools

Symptom/emotionTool

Itch and pain Visual analogue scale

Impact on quality of lifeDermatology 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

Suicidal ideation

Alcohol Use Disorders Identification Test (AUDIT)

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

Roles and responsibilities of dermatology nurses in assessment of patients

BandClinical skills*

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 concer ns 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.

Investigations

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

Investigations used to assess the skin

InvestigationIndication

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 scrapingTo confirm dermatophyte infection and treatment sensitivities

Blood testsTo identify inflammation, systemic disease and infection, and monitor the effects of systemic medication

Wood’s lightTo confirm vitiligo and fungal infections

Biopsy (punch or ellipse excision)

For histological diagnosis

DermoscopyFor diagnosis of lesions

To identify scabies mites

Patch testingTo identify type 4 allergic contact sensitivity

Prick testingTo 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.

Roles and responsibilities of dermatology nurses completing investigations

BandClinical skills

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 concer ns 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.

Contact Dermatitis Research Group criteria for

patch test results

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

reaction

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

Roles and responsibilities of dermatology nurses in patch testing

BandClinical skills

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

Roles and responsibilities of dermatology nurses in patch testing

BandClinical skills

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.

Using topical treatments

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.

Roles and responsibilities of dermatology nurses in application of topical treatments

BandClinical skills

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

As above, plus:

Uses a wide range of strategies to promote adherence

Monitors treatment response

Supports the education of peers on topical therapeutics

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

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)

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.

Courses and training

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.

Next steps

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.

Examples of useful resources for further learning

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-lear ning.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

Examples of useful resources for further learning

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

Key points – practical skills

• 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.

References and resources

1. National Institute for Health a nd 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. Sk in Support Psychodermatology. The Psychosocial Aspects of Skin Conditions. Skin Support. www.skinsupport.org.uk/ content/psychodermatology, last accessed 1 June 2022.

3. Nu rsing 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. Al lergy 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-SkinDeep-min-compressed.pdf, last accessed 29 December 2021.

6. Br itish 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. Br itish 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/BADBDNG-RCN-NURSINGWORKSTREAM-A4LANDSCAPE-002.pdf, last accessed 20 June 2021.

Further reading and resources

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.

The incidence of skin cancer in the UK is rising: in 2016–2018 there were around 156 000 new cases of non-melanoma skin cancer per year (a 42% increase over the last decade) and 16 700 new cases of melanoma skin cancer per year (a 32% increase over the last decade).1,2 Furthermore, as basal cell carcinoma is not included in cancer registry data, exact numbers are likely to be higher. In 2017, melanoma skin cancer was the fifth most common cancer in the UK, accounting for 4% of all new cancer cases, and the incidence is predicted to continue to rise by 7% between 2014 and 2035.2

Nursing role

Nurses working in skin cancer have traditionally come from a dermatology or plastic surgery background. However, with the arrival of targeted treatments and immunotherapy, particularly for melanoma, the number of melanoma oncology and research nurses joining the specialty has increased.

Most nurses working in skin cancer are clinical nurse specialists (CNS), a role that became more common after publication of a National Institute for Health and Care Excellence (NICE) cancer service guideline entitled Improving Outcomes for People with Skin Tumours Including Melanoma 3 Subsequent skin cancer measures published through the Quality Surveillance Programme included a requirement for all patients with a skin cancer diagnosis to have access to a skin cancer CNS. This resulted in the recruitment of skin cancer CNSs in all UK hospitals. The role can vary according to service needs, and in many places it is still evolving.

Many of the skin cancer nursing roles are sponsored by Macmillan and those CNSs will have Macmillan as part of their title. As in many areas of specialist nursing practice, titles and roles may vary, for example:

• skin cancer CNS (with or without Macmillan prefix)

• melanoma CNS (with or without Macmillan prefix)

• skin cancer advanced nurse practitioner

• skin cancer nurse consultant.

Scope of practice. The Agenda for Change (AfC) banding awarded to nurses specialising in this field in the UK has been inconsistent. The BDNG role descriptors provide some generic guidance in this area

(see page 12) and should help to improve consistency around the country.4 Most are employed at CNS level, AfC band 7, and have:

• a qualification at Masters level (MSc), or are working towards one

• an expert knowledge base (educators)

• the ability to work autonomously

• complex decision-making skills and clinical competences for extended practice

• the ability to manage their own caseload

• the ability to apply evidence-based holistic care

• an independent prescribing qualification

• research skills.

The high level of independent decision-making required means that a skin cancer CNS must work at band 7 or 8. As in other fields of dermatology nursing, the greater the level of independent decisionmaking, particularly around diagnosis and planning and evaluation of therapeutic interventions, the higher the grade. A band 7 CNS will be involved with skin cancer screening and will work independently in complex clinical situations that require liaison and initiative. Undertaking more advanced roles, such as diagnosis, should be reflected by a higher grade of band (8a or above). Figure 3.1 summarises the CNS’s roles and responsibilities.

The patient care setting. Patients with skin cancer are seen in a variety of settings, including chemotherapy units, research departments, outpatient clinics and hospital wards. The skin cancer CNS will usually work within a local skin cancer MDT or specialist skin cancer MDT (there are only two melanoma MDTs in the UK at hospitals that provide specialised melanoma services) comprised of dermatologists, plastic surgeons, histopathologists, medical/clinical oncologists and an MDT coordinator. The MDT discusses each patient with a skin cancer diagnosis and devises a treatment plan. The CNS may sometimes lead the MDT, but primarily advocates for patients and supports both patients and the team.

Supportive role. Any patient who receives a cancer diagnosis will have a variety of responses, ranging from the relief of knowing what the problem is/having a diagnosis to despair. It is essential that patients are given clear and comprehensive information to enable

Core MDT member/leadership within the MDT and wider cancer team

Advanced communication and advocacy skills

In-depth knowledge of tumour area Education/ information

Acting as a key worker across the whole pathway

Autonomous practice Innovation, project and change management

Excellent decisionmaking skills

Skin cancer clinical nurse specialist

Empathy for patients and their families

Advanced clinical and diagnostic skills Auditor/ researcher

Ability to assess patients' holistic needs

Figure 3.1 The roles and responsiblities of the skin cancer CNS are wide and depend on the individual’s competence level/band.

them to make sometimes complex decisions. Empathic support during such a consultation is key to helping patients face their treatment pathway and follow up. In many services, it is the CNS who provides this support and continuity of care (see page 47).

The CNS is usually appointed as the patient’s ‘key worker’ to help them (and those supporting them) make sense of their diagnosis and treatment options, and explain the potential effects of both the disease and the available treatments (Table 3.1).

TABLE 3.1

Supportive role of the key worker/CNS

• Provides contact details

• Provides reassurance and one-to-one care/emotional support

• Helps patient to understand and get through their treatment, including management of side effects or symptoms

• Supports patient while in hospital or attending outpatient clinics

• Ensures good communication between the patient and the MDT

• Liaises with and facilitates communication with and between the patient’s family and other members of the healthcare team (e.g. primary care provider, community nurse, palliative care team, social worker)

• Provides details of support groups and other useful organisations

• Provides details of how to access benefits and financial and welfare advice

Core competencies

The core competencies for nurses working in the field of skin cancer are split over six domains:

• an underpinning knowledge that supports professional practice

• assessment and investigation

• therapeutic interventions and radiological investigations

• caring for the patient

• understanding and managing the psychological effect of living with skin cancer

• patient education and health promotion.5

Each of these competencies is divided into three levels.

• Level 1: nurses new to skin cancer, who may be limited to supporting more senior colleagues and doctors in the provision of patient care.

• Level 2: competent nurses with a minimum level of knowledge and expertise in varied roles, depending on service needs.

• Level 3: specialist nurses in a diverse range of roles, including nurse-led services.

Competence levels are developed over time through education (often to MSc level in a relevant specialist area) and practice. Competence is assessed in a variety of ways, including self-assessment, peer review and case-based discussions. Direct observation of procedural skills (DOPS) and mini clinical evaluation exercises are also important to assess competence in specific practical skills and clinical encounters with patients, respectively.

Knowledge. Nurses working in skin cancer must demonstrate awareness, knowledge and understanding (depending on competence level) of benign and malignant skin lesion recognition, nonmelanoma and melanoma epidemiology (including risk factors and causes), and national/local guidelines and policies in relation to clinical practice. The skin cancer CNS should have a comprehensive knowledge in all these areas, as well as the ability to critically discuss and disseminate the knowledge to others.

Assessment and investigation. In the UK, individuals are referred on a 2-week wait pathway by primary care providers to dermatology clinics designated to deal with cancer referrals. The healthcare professionals who run these clinics, including the CNS, aim to assess, diagnose and plan treatment/investigation or reassure and discharge. Patient history. Risk factors for skin cancer include fair complexion, freckles, red/blond hair and blue eye colour, inability to tan, a history of prolonged sun exposure and/or severe sunburn and high sunbed use. In addition, people with multiple normal or atypical nevi (moles) may be more at risk. Some people may have a genetic predisposition for skin cancer, or may have other medical conditions (for example, if they are immunosuppressed) that put them more at risk. The CNS must take all these factors into consideration when taking the patient’s history, as well as finding out the history of the lesion itself – how long the patient has had it and whether it has changed during that time.

Lesion assessment. Dermoscopy (or dermatoscopy) is examination of the skin using skin-surface microscopy. It allows for inspection of skin lesions unobstructed by skin-surface reflections, enabling the CNS

to differentiate benign lesions from premalignant and malignant lesions (Figure 3.2).

Further investigation. For all suspected malignant skin lesions, a biopsy will confirm the diagnosis. The CNS will prepare and support patients undergoing further investigation of skin lesions and, depending on competence level, will either perform the relevant surgical intervention or refer the patient to another member of the MDT. For more information on skin surgery see Chapter 4. Biopsy results are interpreted and actioned in liaison with the MDT, and will enable staging of melanoma according to the 8th editions of the Union for International Cancer Control’s tumour-node-metastasis (TNM) classification of malignant tumours and the American Joint Committee on Cancer (AJCC) melanoma staging system.5,6 A holistic needs assessment (HNA) should also be performed after diagnosis.

(a) (b)

Figure 3.2

Examples of benign and malignant lesions. (a) benign compound nevis; (b) premalignant actinic keratosis on patient’s forehead; (c) malignant lentigo maligna melanoma on a sun-exposed area; (d) malignant superficial spreading melanoma.

Therapeutic interventions. The management of melanoma and non-melanoma skin cancer is subject to national guidelines.7–13 Skin cancer nurses must demonstrate understanding of different therapeutic options for patients within the MDT setting. Treatment can be complex and many factors, including the different treatment modalities and their side effects, risks, benefits, expectations of treatment and trial options, need to be considered and discussed with the patient. The skin cancer nurse plays an important part in guiding and supporting the patient and family through the appropriate information at what is inevitably a difficult time and helping them to make informed treatment choices, while fostering trust and rapport.

Skin cancer nurses of band 8 or above may plan and administer treatment, as well as mentoring colleagues who are learning new procedural skills. Excisional surgery is the gold standard for the treatment of most established skin cancers (see Chapter 4), but there are also several non-surgical options (Table 3.2). An important element of the skin cancer nurse’s role is to support patients through the side effects of treatment, which in some cases may be life threatening.

TABLE 3.2

Non-surgical treatments for premalignant and malignant skin lesions*

Topical therapies

• Used to treat premalignant and non-melanoma skin cancer

• Chemotherapy (e.g. 5-fluorouracil) or immunotherapy (e.g. imiquimod) creams

• Side effects include redness and tenderness, flaking, peeling, crusting and itching Cryotherapy

• Used to treat actinic keratoses (premalignant lesions)

• Application of liquid nitrogen to the skin to freeze and destroy precancerous cells

• May need more than one treatment; may leave small white scar on skin

Curettage and electrocautery

• Used to treat some non-melanoma skin cancers

• After injection of local anaesthetic, lesion is scraped off with curette and heat is applied to wound surface

• Takes 2–3 weeks to heal; often leaves a scar

Photodynamic therapy

• Used to treat some non-melanoma skin cancers

• Combines a light-sensitive drug with light treatment to optimise cancer cell death

• Side effects include stinging/bur ning during treatment and redness/ swelling for several days after treatment; final cosmesis is good

Radiotherapy

• Used to treat some non-melanoma skin cancers in areas where surgery may be difficult or if resection was incomplete or close to margin in difficult-to-treat anatomical areas

• Number and duration of sessions vary depending on histology and site of lesion

• Side effects include redness and swelling for up to 1 month after treatment; may cause scarring

• Can be used in melanoma brain metastases to control symptoms, but not with curative intent

Targeted systemic therapies (see Chapter 6)

• Oral treatment for advanced non-resectable melanoma in patients with certain gene mutations (e.g. in BRAF, MEK genes)

• Slows growth of tumour and prolongs survival; may also be used after surgery (adjuvant therapy) to reduce risk of recurrence

• Combinations of drugs may be given

• Common side effects include rash, nausea, diarrhoea, itching and sensitivity to sunlight

• Less common but serious side effects include bleeding, infections, and heart, liver and eye problems

TABLE

Non-surgical treatments for premalignant and malignant skin lesions*

Immunotherapy

• Used to treat advanced non-resectable melanoma; may also be used as adjuvant treatment after surgery to reduce risk of recurrence

• Helps the body’s immune system to recognise and kill cancer cells

• Immune checkpoint inhibitors (e.g. pembrolizumab, nivolumab, ipilimumab) are given as multiple infusions every few weeks over several months

• Common side effects include fatigue, cough, nausea, rash, poor appetite, constipation, joint pain and diarrhoea

• Serious side effects include allergic infusion reactions and lifethreatening autoimmune reactions (organ-related problems)

• T-VEC (talimogene laherparepvec) ia an oncolytic virus therapy, injected directly into melanoma in the skin or lymph nodes every 2 weeks; common side effects include fatigue, pain at injection site and flu-like symptoms

Chemotherapy and electrochemotherapy

• Used to shrink advanced melanoma, usually as second-line treatment after immunotherapy or targeted drugs; administered orally or by injection

• Isolated limb perfusion or isolated limb infusion can be used under general anaesthetic to confine high doses of chemotherapy to a single limb (reduces side effects). Side effects depend on type of drug (or combination of drugs) and dose, but include fatigue, hair loss, mouth ulcers, nausea and vomiting, diarrhoea or constipation, loss of appetite, increased risk of infection, and bleeding and bruising

• Electrochemotherapy, usually given under general anaesthesia, combines low-dose intravenous chemotherapy with a small electrical current applied directly to a tumour; with the electrical current, lowerdose chemotherapy can penetrate the cancer cells more easily

*Non-exhaustive list: new treatments and/or combinations are always in development.

Caring for the wellbeing of the patient. Patients’ need for information varies and may change at different points of their cancer pathway. It is important to address their concerns and fears, involve them in the decision-making process, and help to promote patient wellbeing and quality of life. In addition to physical treatments, all patients with a diagnosis of squamous cell carcinoma (SCC) or melanoma are offered an HNA as part of a ‘recovery package’. The HNA, which is usually offered at diagnosis and at different points in the patient care pathway, is a discussion about the patient’s physical, psychological, spiritual and social needs. It can be carried out by any member of the MDT, but it is usually part of the CNS’s role. It can help to address specific concerns and needs and allows an individual care plan to be developed that may include signposting and referral to additional support services.

Patient education and health promotion. It is important for the CNS to identify factors that may be detrimental to the patient’s health (for example, reasons for non-adherence to treatment) as well as building the patient’s self-esteem and confidence and actively promoting self-management options to empower them. Health promotion should include information on:

• sun protection

• self-examination of skin and, if appropriate, lymph-node basins

• other family members’ risk of skin cancer

• vitamin D3 supplementation

• healthy living

• organ/blood donation

• additional support: for example, financial services

• survivorship.

Communication skills

All members of the MDT who deliver cancer diagnoses, including the skin cancer CNS, are required to attend an ‘advanced communication course’, usually facilitated by various local cancer alliances (Table 3.3). Healthcare professionals tend to have limited training in this area, particularly in relation to delivering ‘bad news’. This can make it a poor experience for patients and their families, compromising therapeutic relationships.

Key aspects of an advanced communication course

• Increases awareness of the participant’s own communication skills

• Explores strategies to improve the quality of clinical communication

• Increases ability to deliver information effectively

• Increases confidence in responding to difficult communication situations and enhances interpersonal communication

• Provides the opportunity to work on real-life clinical challenges (the course is experiential and learner led)

• Includes discussion of research on communication in cancer care, interactive exercises and role play in small groups with actors

• Provides a safe and supportive environment to practise skills and receive feedback

• Provides CPD points and a certificate on completion: the course is a peer-reviewed requirement for all MDT members seeing patients with skin cancer, led by accredited, nationally approved facilitators CPD, continuing professional development.

Such conversations are also difficult for the healthcare professional. Every CNS working with patients with skin cancer (melanoma or SCC) will have access to clinical supervision with a trained psychologist or psychotherapist. This is a formal and mandatory process of professional support that enables the healthcare worker to share their feelings and discuss situations with peers in a supportive confidential environment.14

Challenges and opportunities

As the incidence of skin cancer continues to increase, services have generally struggled with capacity, especially complying with cancer waiting-time targets.15 Workforce challenges, including too few consultant dermatologists, have led to opportunities for the skin cancer CNS to develop more advanced roles and services. Specific roles in skin surgery are discussed in Chapter 4.

Given the many new therapies being developed to treat advanced melanoma, clinical trials of new or combination drugs are becoming

increasingly available to patients. This may mean expanded roles for the skin cancer CNS in identifying patients who are eligible for clinical trials and responding to researchers’ data requests, for example recording and reporting adverse events that occur while the patient is involved in the study. The CNS will be important in maintaining effective communication between patients, carers and all healthcare professionals involved in their care to ensure high-quality service delivery. Future trials evaluating survivorship and quality of life after new treatments may also involve the skin cancer CNS, for example in extended follow-up of patients and data collection.

Next steps

If you are interested in a career in skin cancer nursing, talk to a skin cancer CNS at any UK hospital; most will be happy to discuss the role and advise on where to find further information. Also consider joining the BDNG and British Association of Skin Cancer Specialist Nurses (BASCSN) for access to useful online resources, study days and conferences. The BDNG has a subgroup for skin cancer nurses, offering contact, support and training. Other useful resources to learn more about skin cancer are outlined in Table 3.4.

TABLE 3.4

Examples of useful resources for further learning

British Association of Skin Cancer Specialist Nurses www.bascsn.com

Cancer Research UK www.cancerresearchuk.org

DermNet NZ www.dermnetnz.org

Macmillan Cancer Support www.macmillan.org.uk

Melanoma Focus www.melanomafocus.org

Melanoma UK www.melanomauk.org.uk

Primary Care Dermatology Societywww.pcds.org.uk

Skcin: The Karen Clifford Skin Cancer Charity www.skcin.org

Familiarise yourself with local and national skin cancer guidelines,7–13 and consider higher education options: for example, the MSc in skin lesion management at the University of Hertfordshire.16

Personal reflection

Working in skin cancer has been a very rewarding experience. I have been privileged to work in excellent MDTs, where patients’ interests were always at the centre of decision-making, but where it was also recognised that sharing expertise and knowledge and supporting each other was, and is, integral to a well-functioning service that benefits patients. I have also been fortunate to practise at a time when treatment options for melanoma have significantly changed, leading to better outcomes for patients. Although, because of these developments, discussions with patients have become more complex, as an advocate of patient choice it is immensely satisfying to help patients make informed decisions that are right for them.

As the incidence of skin cancer continues to rise, the role of the skin cancer CNS and advanced nurse practitioner will continue to be much needed. There will be many opportunities to expand roles, including involvement in national and local guidelines, with the possibility of influencing patient care policies.

Having been involved in some of the skin cancer MSc programmes, I strongly recommend taking the opportunity for academic learning to support clinical practice in this area, as it facilitates evidence-based practice and ultimately helps our patients.

I recommend joining the skin cancer nursing groups mentioned above, as peer support, sharing knowledge and meeting colleagues is so important, especially as, for some, the role can be an isolated one.

Key points – skin cancer

• Most nurses working in skin cancer are a CNS or advanced nurse practitioner at band 7 or above with or working towards an MSc academic qualification.

• All patients with a skin cancer diagnosis should have access to a CNS; the CNS is usually appointed as the patient’s key worker to support them through diagnosis, treatment and follow up.

• Underpinning knowledge that supports clinical practice includes recognition of benign and malignant skin lesions, awareness of non-melanoma and melanoma epidemiology, and an understanding of relevant guidelines and policies.

• The skin cancer CNS is an integral member (sometimes leader) of the MDT, which determines the patient’s treatment plan.

• The CNS must guide and support the patient and their family through surgical and non-surgical treatment options, including the management of side effects, which in some cases may be life-threatening (for example, the autoimmune reactions associated with immunotherapy).

• Patient education and health promotion are vital. All patients with a diagnosis of SCC or melanoma are offered an HNA to discuss their physical, psychological, spiritual and social needs.

References and resources

1. Cancer Research UK. NonMelanoma Skin Cancer Statistics Cancer Research UK, 2016–2018. www.cancerresearchuk. org/health-professional/cancerstatistics/statistics-by-cancertype/non-melanoma-skincancer, last accessed 22 March 2022.

2. Ca ncer Research UK. Melanoma Skin Cancer Statistics. Cancer Research UK, 2016–2018. www. cancerresearchuk.org/healthprofessional/cancer-statistics/ statistics-by-cancer-type/ melanoma-skin-cancer, last accessed 22 March 2022.

3. National Institute for Health a nd Care Excellence. Improving Outcomes for People with Skin Tumours Including Melanoma. Cancer Service Guideline [CSG8]. National Institute for Health and Care Excellence, 2006 (updated 2010). www.nice.org.uk/guidance/csg8, last accessed 22 March 2022.

4. Br itish 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/BADBDNG-RCN-NURSINGWORKSTREAM-A4LANDSCAPE-002.pdf, last accessed 20 June 2021.

5. Ke ung EZ, Gershenwald JE. The eighth edition American Joint Committee on Cancer (AJCC) melanoma staging system: implications for melanoma treatment and care. Expert Rev Anticancer Ther 2018;18:775–84.

6. Br ierley JD, Gospodarowicz MK, Wittekind C, eds. TNM Classification of Malignant Tumours, 8th edn. Wiley-Blackwell, 2016.

7. Ke ohane SG, Botting J, Budny PG et al. British Association of Dermatologists guidelines for the management of people with cutaneous squamous cell carcinoma. Br J Dermatol 2021;184:401–14.

8. Ma rsden JR, Newton-Bishop JA, Burrows L et al. Revised UK guidelines for the management of cutaneous melanoma 2010. Br J Dermatol 2010;163:238–56.

9. National Institute for Health and Care Excellence. Melanoma: Assessment and Management. NICE guideline [NG14]. National Institute for Health and Care Excellence, 2015. www.nice.org. uk/guidance/ng14, last accessed 22 March 2022.

10. Na sr I, McGrath EJ, Harwood CA et al. British Association of Dermatologists guidelines for the management of adults with basal cell carcinoma 2021. Br J Dermatol 2021;185:899–920.

11. Newlands C, Currie R, Memon A et al. Non-melanoma skin cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol 2016;130(Suppl 2):S125–32.

12. Scottish Intercollegiate Guidelines Network. SIGN 140: Management of Primary Cutaneous Squamous Cell Carcinoma. A National Clinical Guideline. Scottish Intercollegiate Guidelines Network, 2014. www.sign. ac.uk/media/1094/sign140.pdf, last accessed 14 March 2022.

13. Scottish Intercollegiate Guidelines Network. SIGN 146: Cutaneous Melanoma. A National Clinical Guideline. Scottish Intercollegiate Guidelines Network, 2017. www.sign. ac.uk/media/1082/sign146.pdf, last accessed 14 March 2022.

14. Hession N, Habenicht A. C linical supervision in oncology: a narrative review. Health Pyschol Res 2020;8:8651. 15. NH S England. Cancer Waiting Times. www.england.nhs.uk/ statistics/statistical-work-areas/ cancer-waiting-times, last accessed 24 March 2022.

Further reading and resources

Agnew KL, Bunker CB, Arron ST. Fast Facts: Skin Cancer, 2nd edn. S. Karger Publishers Ltd, 2013.

Melanoma Focus [online]. www.melanomafocus.org

16. Un iversity of Hertfordshire. MSc Skin Lesion Management [course details]. www.herts.ac.uk/ courses/postgraduate-masters/ msc-skin-lesion-management, last accessed 2 April 2022.

Melanoma UK [online]. www.melanomauk.org.uk

SKCIN: The Karen Clifford Skin Cancer Charity [online]. www.skcin.org

The incidence of skin cancer in the UK is increasing (see page 38). In response to this trend, many UK dermatology services have proactively transformed their workforces by training first-level registered nurses to become competent in skin surgery at different skill levels. Here, we outline the role of nurses performing skin surgery and the clinical governance that provides training opportunities for a large portfolio of evidence-based competencies within a range of clinical settings and responsibilities.

The GIRFT national dermatology report, published in 2021, acknowledges the world-leading status of British dermatology nursing. The report confirms that nurses now perform dermatological surgery, a role previously reserved for doctors, and that dermatology capacity is improving in settings where nurses are being trained and utilised in this field. The report stresses that nurses performing these roles must be supported by a consultant dermatologist-led team.1

Nursing role

Roles in dermatological surgery vary from diagnostic minor surgery to advanced-level excisions (Table 4.1). Although there are differences in nurse training, background and service delivery for skin surgery across the UK, for most nurses it is an extended role that requires background experience in skin lesion recognition, both benign and malignant.

The patient care setting. Minor dermatological surgery can be performed in various settings provided the clinical governance for patient safety has been met. These include community- and hospitalbased dermatology services, dermatology nurse-led services in primary and secondary care, and private-care clinics.

Core knowledge domains. The rationale is to develop nurses with competence in technical procedures that is underpinned by knowledge. For example, nurses undertaking surgical roles must understand why a particular procedure is appropriate for the diagnosis. Therefore, surgical competence is best supported by general dermatology education and skills (Table 4.2). Particular benefit is gained from having an assessed knowledge and clinical experience of skin lesion recognition and the use of dermoscopy. These are

TABLE 4.1

Minor and advanced surgical procedures

Minor procedures

• Punch biopsy/excision

• Shave biopsy/excision

• Curretage and cautery

• Snip excision

Advanced procedures

• Elliptical excision

• Incisional biopsy

• Excision and full-/split-thickness skin graft repair

• Simple flap*

• Wedge excision (ears)*

• Excision with secondary intention healing*

*Competency framework not included in this chapter. Local policy and competency training advised, following core aspects.

important skills that complement dermatological surgery and improve patient experience and outcomes.

Given that surgical lists are often populated by other clinicians and lesions can evolve in terms of size and symptoms, the nurse must be able to question the procedure before starting it and seek advice to ensure the patient receives the most appropriate procedure for their skin presentation on the day of surgery. A differential diagnosis may need to be considered, leading to an alternative procedure.

Scope of practice. The BDNG role descriptors for dermatology nurses (see page 12) clearly define the suggested scope of practice and align with AfC banding (see page 38).2 The BDNG document includes recommendations for banding associated with a particular level of practice. For example, band 5 nurses would not perform surgical procedures independently, while advanced surgery may be undertaken by nurses with higher banding as part of an advanced practice role and could include further expertise in the management of patients

TABLE 4.2

Knowledge domains underpinning surgical skills

• Skin assessment

• Anatomy of skin and nerves, in particular recognising danger zones for surgery

• Consent process and mental capacity assessment

• Clinical risk assessment, including assessment of correct site of lesion/ area before surgery commences (to avoid wrong-site surgery)

• Margin control (for more advanced surgery)

• Infection control and sterile technique

• Dermoscopy examination

• Use of photographic images

• Non-surgical interventions (e.g. topical options, cryotherapy; see Table 3.2) and when these may be more appropriate than surgery

• Head and neck anatomy for identification of danger zones

with skin cancer. Banding at a local level will be determined by a combination of factors, including the level of independent clinical decision-making and responsibilities in other domains (for example, leadership) against the backdrop of specific service need. For most nurses, a skin surgery role is likely to form part of a wider job description. However, it is recommended that all levels of skin surgery nurses should spend at least 50% of their clinical time using these skills in order to maintain competence.

Trust protocols for skin surgery

As skin surgery is considered an extension to a nursing role, a ratified Trust protocol approved by the relevant governance structures must be in place. Such a protocol should include:

• identification of the patient groups that nurses can care for, with clear inclusion and exclusion criteria

• well-defined referral criteria

• a clear patient pathway, including how the patient will be followed up and what happens if they do not attend follow up

• lines of accountability and responsibility, with detail of clinical supervision

• how competence is recorded, including the importance of reflecting new skills and roles within job descriptions.

The protocol should be supported by a specific scope of practice and competency framework to ensure the nurse possesses the knowledge, skills and abilities required for lawful, safe and effective professional practice. The scope of practice, detailing the functions that can be carried out at each band, should be cross-referenced to the overarching protocol. Core competencies should form the basis of competent dermatological surgery, but to make a competency framework that is fit for purpose in each environment, consideration will need to be given to specific local service and patient needs.

Nurses deliver skin surgery via a number of different patient pathways depending on how individual services are set up. When establishing a nurse-led skin surgery service it is critical to be clear about these pathways as they will require different levels of competence. The initial part of any patient assessment prior to a nurse-led surgical intervention should ask the following questions.

• Has the lesion resolved or increased in size?

• Does a change in the lesion take the procedure outside the scope of practice of the nurse?

These questions are particularly important if there is a significant time lag between the patient being added to the nurse’s list and the scheduled surgery. If the answer to either of these questions is ‘yes’, then the nurse should consult with a senior clinician or the person who originally referred the patient to determine next steps. Once it has been confirmed that it is still appropriate for the nurse to remove the lesion, the following checklist should form part of the nursing assessment.

• Is the patient still happy for the procedure to go ahead?

• Has documented informed consent been obtained, considering: – the mental capacity of the patient

– whether the patient’s general health poses an unacceptable clinical risk?

• Is there any change in the lesion that may require a different management plan?

• Has postoperative care been discussed with the patient, including:

– how to look after the wound

– what to do if there are signs of bleeding or infection

– what sort of follow up will be required

– what to do in case of an emergency?

Competence levels

Comprehensive and robust clinical governance must be established for all nurses performing skin surgery, with a clear scope of practice that is competence-based and covers all elements of the surgical service that the nurse provides. This includes SOP, with clear provision of clinical supervision and exclusion and inclusion criteria. Clinical supervision must cover all areas of skin surgery, including:

• obtaining consent

• documentation

• performing biopsies and/or excisions to a good standard

• monitoring surgical margins/keeping an accurate surgical log

• lidocaine infiltration.

Competence levels, as recommended in Table 1.2 (see page 16), should reflect the contents of the service protocol and scope of practice. Competence levels can be set for each function of skin surgery (Table 4.3) and should be monitored using work-based assessment tools, including DOPS, case-based discussions, mini clinical evaluation exercises (direct observation of an interaction with a patient), feedback from multiple sources (including colleagues and patients) and patient experience surveys.

Ensuring patient safety and best outcomes

Performing minor and advanced dermatological surgery carries considerable clinical responsibility and accountability. Potential complications, such as infection at the surgical site and postoperative scarring, together with the risk of wrong-site surgery must be considered and managed appropriately. Robust protocols that align with a competency-driven scope of practice must be in place. Clearly outlined exclusion and inclusion criteria for procedures are needed, along with a named clinical supervisor (for example, consultant

framework for each function of nurse-led skin surgery

Theoretical measures

• Understands rationale for informed consent

Demonstrates knowledge of the principles of obtaining informed consent

Identifies circumstances wher e specialist advice may be needed

Performs mental capacity assessment where appr opriate, according to Trust policy and mandatory training requirements

• Understands the legal requir ements of lasting power of attorney

Understands the concept of a ‘best interest’ decision and how it is carried out in line with local policies

measures

Gives patient appropriate information

Provides patient information in clear and r elevant language

Ensures patient has full understanding and awar eness of the procedure

Can answer routine questions asked by patients befor e skin surgery

Fully explains any alternative tr eatments or the implications of no treatment

Discusses the expected and potential cosmetic outcome

Accurately recor ds information on relevant consent form

Informed consent

Understands indications, cautions and contraindications of procedur e*

Describes potential complications †

Describes how complications/untoward r eactions would be managed*

Identifies situations where specialist advice may be r equired*

All procedures• Effectively pr epares patient physically and psychologically for the procedure*

Checks anaesthesia is adequate before starting pr ocedure*

Uses correct surgical instruments/equipment pr oficiently †

Safely and effectively performs pr ocedure according to local guidelines/protocol*

Achieves haemostasis using an appropriate technique (e.g. subcutaneous suture[s] for punch biopsy) †

Assesses patient discomfort and uses effective methods of r elief †

Collects specimens appropriately and corr ectly completes histology form ‡

Accurately recor ds procedure in patient’s records*

Effectively communicates advice and after care to patient †

Correctly disposes of, disinfects and maintains equipment*

As for all procedures,* plus:

Demonstrates knowledge of structure, function and anatomical hazar ds of the skin

Describes action of local anaesthetic on the skin

As for all procedures,* † plus:

Identifies appropriate sutur e material for procedure and anatomy

Provides appr opriate aftercare advice for suture removal

Understands and works to local policy for needle stick injuries; takes responsibility for safe disposal of sharps after pr ocedure

As for all procedures,* plus:

Accurately calculates safe dosage levels

Lidocaine anaesthetic infiltration

Draws up and checks local anaesthetic correctly

Checks effectiveness of local anaesthetic during the pr ocedure

Gives appropriate advice to patient about duration and side ef fects of anaesthetic

As for all procedures,* † plus:

Selects appropriate sutur e material

Demonstrates appropriate suturing technique: placement, knot tying, appearance of final incision

Selects appropriate dr essing

Interrupted sutures/deep dermal sutur es (advanced)

Punch biopsyAs for all procedures* †‡

As for all procedures* †

As for all procedures,* †‡ plus:

As for all procedures* † Curettage and electrocautery

Ensures cur ettage is most appropriate procedure to analyse the lesion histologically

for each function of nurse-led skin surgery

measures

As for all procedures* †

measures

As for all procedures,* †‡ plus:

• Ensures shave biopsy is most appr opriate procedure to analyse the lesion histologically

Shave biopsy/ excision/snip

As for all pr ocedures* †

As for all procedures,* †‡ plus:

• Performs adequate and complete excision of lesion with appropriate choice of pr ocedure

Ellipse excision/ incisional biopsy (advanced)

• Has comprehensive knowledge of surgical margins depending on clinical diagnosis

• Understands the importance of scar orientation and use of orientation marker sutures

Note: each of the competencies described here can be attained at levels 0–5 (see Table 1.2).

† All procedures except lidocaine anaesthetic infiltration. ‡ All procedures except lidocaine anaesthetic infiltration and suturing.

*All procedures.

dermatologist, plastic surgeon or consultant nurse) who can collate competency work-based evidence assessments.

It is a firm recommendation that skin surgery should not be carried out in an isolated situation where no backup or supervision is available to support patient and nurse safety. Even in minor surgery, adverse events can occur such as fainting/collapse, cardiac episodes, allergic reactions and panic attacks.

The combination of technical ability and diagnostic skills is supported by a well-structured training programme that promotes patient safety together with appropriate professional development. This is important as, in the event of litigation, root cause analysis or significant/never events (Box 4.1), it can be demonstrated that the individual practitioner has not only worked within their scope of

BOX 4.1

Definitions Root cause analysis3

• A quality governance procedure used to investigate adverse events

• Raised as part of a critical incident/significant event where there is the potential for harm

• Looks at clinical governance and protocols, including competencies where appropriate

• Aims to discover the root cause of the problem and identify appropriate solutions

Never events4

• Identified by NHS England as serious incidents that are preventable

• Wrong-site surgery is considered a never event. Protocols for nurse-led procedures to avoid wrong-site surgery should include:

Patient photographs to identify the area

Patient to agree to surgical site at consent

Use of a mirror to assist patient’s identification of the area

Use of previous consultation notes to assist in identifying the area

Seeking a second clinical opinion if there is any clinical doubt about the surgical site

practice/protocols but also has overarching accredited training and qualifications.

Courses and training. The competency framework outlined in Table 4.3 demonstrates that training and education are paramount in this field. For both minor and advanced skin surgery, training and education should encompass both work-based learning and academic study to ensure the best learning outcomes and most effective patient care.

Work-based learning should be undertaken with appropriate clinical supervision using work-based assessment tools. Used in combination with protocols and scope of practice the nurse can collate assessment evidence to be signed off as competent at levels 0–5 (see Table 1.2, page 16). Competencies should be reassessed on an annual basis and form part of the nurse’s appraisal process.

Academic study comprises a formal accredited university-led module with a clinical portfolio of evidence and OSCE.

Identifying training needs. Some nurses may already be practising dermatological surgery through work-based assessment with no external verification or learning.5 It is therefore critical that clinical skills remain up to date and that the competencies of all staff are continuously assessed. External qualifications are recommended to support in-house training. A validated surgical course will complement and enhance technical ability while underpinning the important background knowledge required to perform procedures and promote sustainable clinical governance. In addition, job descriptions should reflect the enhanced skills required to perform dermatological surgery.

At annual review, training or educational needs should be identified and plans made to achieve them. These may include accessing the BDNG’s online resources, study days and conferences, such as the 2-day taster course ‘Introduction to Skin Surgery for Nurses’. Higher education options include an MSc in skin lesion management at the University of Hertfordshire, which has a skin surgery skills module.6

Minimum standards for staffing and facilities.7 All staff should be appropriately supported during surgical interventions, with at least one support nurse (two for more advanced surgery), as well as

access to secretarial and administrative support. All staff must keep up to date with mandatory training, in particular cardiopulmonary resuscitation, and know the location of their nearest resuscitation trolley, in line with the Trust’s resuscitation policy.

Skin surgery nurses should have access to senior clinical advice and support within their departments in case of adverse incidents or if they run into difficulties. Working as a sole practitioner with no onsite backup is not advocated.

All surgical procedures must be undertaken in an appropriate clinical space used solely for surgery (Table 4.4).

TABLE 4.4

Minimum standards for skin surgery facilities7

• Reception and waiting area/recovery area for day-case procedures

• Dedicated operating facility (used solely for surgery)

– Adequate size

– Clean room with wipe-clean surfaces

– Clear of clutter

– Wheelchair access

• Operating couch

• Suction/smoke extraction

• Ideally, hands-free theatre-style sink with wall-mounted antiseptic/scrub materials

• Good lighting

• Good quality instruments/sharps box

• Electrosurgical generator (e.g. unipolar/bipolar Hyfrecator®)

• Telephone and emergency call buttons

• Computer access

• Patient changing area with curtains or screen

• Nearby resuscitation equipment

• Access to relevant histology equipment (e.g. pots)

• Postoperative information for patient

Ongoing monitoring. An annual audit should be carried out, measuring the following against agreed organisational standards.

• Patient experience.

• Infection control, ensuring correct aseptic non-touch technique and adherence to infection control policies.

• Use of Local Safety Standards for Invasive Procedures (LocSSIP) or World Health Organization surgical check lists as part of clinical risk assessments.

• Margin control for advanced surgery (this forms part of an individual’s annual competency assessment).

• Documentation, including consent forms, ensuring they adhere to Trust/local policies.

• Surgical site infection, monitoring infection trends, patient aftercare information and appropriate antibiotic use.

• Attendance at skin cancer MDT meetings (80% attendance is required for those practising advanced surgery). Performance review. The skin surgery nurse’s annual performance review should run alongside a portfolio of competency evidence that includes work-based assessment, training and education. The annual review should identify any professional development needs and/or knowledge deficits so that appropriate training can be planned. It is also the ideal time to ascertain that appropriate clinical supervision is still in place and is adequately supporting nursing staff.

Trust-based protocols and scopes of practice should also be reviewed annually to ensure they remain fit for purpose.

Meeting service needs. An annual assessment should also be made to determine whether service needs continue to be met. This may include:

• assessing the need for succession planning and training of new staff

• acting on feedback from patient surveys

• ensuring there are adequate numbers of support staff and that they are trained appropriately

• ensuring the environment meets infection control standards for dermatological surgery

• ensuring equipment is always of an acceptable standard and in full working order.

Meeting nurses’ needs. Alongside the support of immediate colleagues, the development of nurses to perform surgical procedures requires good management and provision of the appropriate infrastructure to support their clinical activity. Consequently, to ensure the viability and sustainability of nurses undertaking skin surgery, capacity issues in overstretched departments, such as limited room space or shortages of support staff, must be addressed. Clinical supervision must always be in place, so daily clinic planning must take into consideration medical vacancies, staff sickness and annual leave; rosters need to reflect the governance required for clinics to go ahead.

Senior nursing and managerial staff need to be engaged to ensure they understand the clinical nurse activity involved in undertaking surgical procedures. This avoids any misunderstanding or misconceptions about the role and ensures that clinical governance is robust at an organisational level.

Next steps

If you are interested in a career in skin surgery, network with other nurses who are already performing this role; most will be happy to discuss the role and advise on where to find further information. Also discuss your interest with your line manager/clinical lead, and present a case for how your development in this area could impact on the department’s capacity and improve patient accessibility.

Find out more about higher education options (see Table 1.1) and funding options. Visit the BDNG website to utilise the online resources, study days and conferences; the BDNG also has a skin surgery subgroup offering contact, support and training.

The future

To meet patient needs, workforce changes in dermatology services mean that patient care will be delivered according to clinical competence rather than strict role boundaries. Nurses and other healthcare professionals, such as physician associates, will continue to develop new skills and take on extended roles such that their jobs will look very different from traditional nursing roles. We hope that the governance recommendations in this chapter help to direct the

nurse and the team they work with towards developing roles that are professionally satisfying but that also enhance patient safety and the quality of care delivered.

Personal reflection

Dermatology is a diverse specialty to work in as a consultant nurse, and the opportunities are there for professional development if you take the initiative and are well supported. It is a career move I have never regretted and know I will continue to enjoy.

Key points – skin surgery

• Skin surgery is usually an extended role for dermatology nurses with knowledge and experience in skin lesion recognition; roles vary from diagnostic minor surgery to advanced-level excisions.

• All levels of skin surgery nurses should spend at least 50% of their clinical time using their surgical skills to maintain competence.

• Competence in surgical procedures must be underpinned by knowledge in a wide range of areas, including skin assessment, anatomy, clinical risk assessment, infection control and non-surgical interventions.

• Core competencies for all skin surgery procedures include obtaining consent, physically and psychologically preparing the patient for the procedure, ensuring the patient receives adequate anaesthesia before the procedure commences, performing the procedure safely and effectively with proficient use of instruments and equipment, achieving haemostasis, assessing and relieving patient discomfort, accurate recording, effective communication of aftercare, and correct disposal and disinfection of equipment.

• Skin surgery should never be carried out in isolation without backup or supervision to support patient and nurse safety, and it should always be undertaken in an appropriate clinical space used solely for surgery with appropriate facilities.

• All skin surgery nurses should receive an annual performance review to reassess competencies and identify training or educational needs. An annual audit of the skin surgery service should also be undertaken to ensure organisational standards and ongoing service needs (for example, adequate staff levels and training) are met.

References and resources

1. Levell N. Dermatology. GIRFT P rogramme National Specialty Report. NHS Publishing, 2021. www.bad.org.uk/ getting-it-right-first-time-girftdermatology-report-launches, last accessed 1 February 2022.

2. Br itish 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 1 February 2022.

3. Ha xby E, Shuldham C. How to undertake a root cause analysis investigation to improve patient safety. Nurs Stand 2018;32:41–6.

4. NH S England. Never Events Policy and Framework. NHS Improvement, 2018. www. england.nhs.uk/publication/ never-events, last accessed 1 February 2022.

Further reading

Price CJ, Sinclair R.

Fast Facts: Minor Surgery, 2nd edn. S. Karger Publishers Ltd, 2008.

5. Eddy L, Duffy R. A study of the skills, education, and qualifications of nurses performing dermatological surgery in the United Kingdom. Dermatol Nurs 2019;18:10–15.

6. Un iversity of Hertfordshire. MSc Skin Lesion Management [course details]. www.herts.ac.uk/ courses/postgraduate-masters/ msc-skin-lesion-management, last accessed 2 April 2022.

7. Br itish Association of Dermatologists. Staffing and Facilities Guidance for Skin Surgery Dermatology Services. Clinical Services Unit British Association of Dermatologists, 2014. https://cdn.bad.org.uk/ uploads/2021/12/29200244/ Staffing-and-Facilities-for-SkinSurgery-Dermatology-ServicesV4-Checked.pdf, last accessed 12 July 2022.

Phototherapy is a therapeutic treatment for a variety of dermatoses, including psoriasis, eczema, mycosis fungoides (an unusual form of skin malignancy) and vitiligo. It involves the controlled administration of non-ionising radiation to the skin in the form of ultraviolet A (UVA) or ultraviolet B (UVB) wavelengths of light.1 UVB is absorbed mainly by the epidermis, while UVA penetrates the deeper layers of the dermis. UVA is usually given as a combination treatment with psoralen, a plant extract that sensitises the skin to light – this is known as PUVA. Ultraviolet light has been used to treat skin conditions for millennia. Up to 3500 years ago, Egyptian and Indian healers used ingestion of plant extracts or seeds in addition to sunlight to treat skin problems.2

The phototherapy clinic is a potentially hazardous environment with powerful UV light sources that can burn both patients and staff if not delivered properly. Therefore, all services must be supported by clear safety protocols along with scopes of practice and specific competency frameworks for staff, with access to specialist support and governance. SOP should be in place to ensure machine safety, including machine maintenance, service dates, how to use the machine in a step-by-step method and comprehensive infection control measures.

Nursing role

Delivering phototherapy has long been a nursing role. Once a patient has consented to and been referred for therapy, nursing teams take on the responsibility of delivering safe and effective care.

Scope of practice. There are roles within phototherapy for band 4 nurses upwards; however, it is a firm recommendation that anyone who works independently with patients receiving phototherapy should be at least band 6. Table 5.1 outlines the roles and responsibilities of dermatology nurses in phototherapy by band, with each band building on the skills outlined in the previous band. Membership of the BDNG is strongly recommended to help keep up to date with evidence-based practice and to be aware of training opportunities.

While band 6 nurses and above can work independently within a phototherapy unit, there should always be access to appropriate clinical support from medical staff in case of adverse events or a

Roles and responsibilities of dermatology nurses in phototherapy

BandClinical skills*

Organises appointments

Chaperones

Assists with safety and infection control

Abides by all safety standards

Delivers phototherapy under supervision (while competence is achieved)

Delivers phototherapy independently alongside someone more senior in the phototherapy unit (after competence is demonstrated)

Provides patient support and education

Attends clinical governance meetings and ensures annual phototherapy updates

Delivers phototherapy independently without the presence of more senior staff in the phototherapy unit

Independent prescriber

• Leads the nursing team (in the absence of a band 7 nurse), contributing to the day-to-day and overall management of the phototherapy unit

Contributes to the development of education in the unit (monitors adverse events, involved in audits, patient education)

Ensures the smooth and safe running of the phototherapy department, including monitoring of staff competence within the unit

Leads on Trust-wide issues related to safety and service delivery

Develops a clinical governance programme and ensures it is delivered

Leads on liaison with named medical consultant for phototherapy

band builds on the skills outlined in the previous band.

deterioration in the patient’s condition. If needed, remote supervision can be arranged.

Direct patient care roles. The phototherapy nurse’s role starts with assessment of the patient to ensure it is safe for them to receive phototherapy. This will require taking a thorough history of previous phototherapy courses, sun exposure, and current and previous medications. The referring consultant will have obtained the patient’s consent for the treatment after outlining possible long-term effects and ensuring they have realistic expectations about the frequency and length of treatment (usually 2–3 times weekly for a minimum of 10 weeks). However, it is important that the phototherapy nurse obtains a second consent after ensuring that the patient knows about the possible immediate adverse effects, what they can and cannot do while having treatment and what they will experience when attending an appointment.

Calculation and delivery of the appropriate dose will depend on the patient’s skin type and skin disease, while safe delivery of the treatment course will require adjustments depending on the patient’s response. The phototherapy nurse will need to keep clear and accurate records, including a note of any adverse events.

The decision of when to discharge the patient will depend on the number of treatments and response to treatment. It is important that the phototherapy nurse organises appropriate follow up to review outcome or to instigate a different treatment modality if phototherapy has not been successful.

Phototherapy nurses must be aware of lifetime limits for both UVB and PUVA, as well as the referral process for skin monitoring when this limit is reached. In this respect, it is also important to liaise with other units to share treatment numbers and dosages (joules) so that cumulative amounts can be recorded. Photonet, the National Managed Clinical Network for Phototherapy in Scotland, is an excellent example of a national system for recording and monitoring cumulative doses.3

The patient care setting. Phototherapy is predominantly delivered in a secondary care, outpatient setting. For hospital phototherapy, consideration must be given to the cost of parking, the patient’s

ability to attend the unit 2–3 times a week, and the overall length of treatment courses. These factors should all be discussed before the patient starts phototherapy to ensure the best treatment pathway is selected. Home phototherapy, which is particularly useful for patients who need to travel long distances to access treatment, has been trialled in a number of places with some good results.4

Competencies

To ensure patients receive optimum care, phototherapy nurses need a good general dermatological knowledge so that they can assess the skin properly, understand how different skin conditions respond to light therapy and advise patients on the use of dermatological treatments. In addition to their dermatological knowledge, nurses working in phototherapy must develop technical abilities to manipulate phototherapy equipment and have confidence to perform regular calculations to ensure correct dose delivery.

Competence must be achieved before a nurse can perform phototherapy independently. When training to achieve competence, the nurse must work under the supervision of a colleague already competent to carry out phototherapy; all patients seen together must be co-signed. A nurse is deemed competent when they possess the knowledge, skills and abilities required for lawful, safe and effective professional practice. Competence can usually be achieved after 3 months of supervised practice (pro rata for part-time workers), but this time frame can be increased as required. The competency framework must be revisited at each annual appraisal to ensure the nurse is still competent.

Core knowledge domains

Alongside general dermatological nursing are some further core knowledge domains, as outlined below.

Monitoring erythema. Erythema is the skin’s natural response to UV light, and it is normal for patients to have some mild erythema after treatment. However, there is a fine line between a normal response and an adverse effect. As such, the phototherapy nurse must develop the skills needed to assess skin erythema. Being able to grade erythema appropriately will determine the course of treatment (that

is, the speed with which treatment is stepped up). If done incorrectly, the patient may receive suboptimal treatment or may be repeatedly overtreated.

An erythema grading chart5 is a helpful tool to guide practice and, ideally, should include images of erythema in non-white skin. Phototherapy nurses must work as a team to ensure a standardised approach to erythema monitoring to ensure safe and effective treatment for patients. Clear documentation is a critical part of this.

Minimal erythema dose testing. The starting dose of UVB phototherapy is critical to the treatment’s effectiveness; getting it right ensures that the patient is not over- or undertreated. Finding the starting dose that is suitable for the individual’s skin is determined in one of two ways, by:

• skin type, using the Fitzpatrick skin type scale (a less accurate method)6

• minimal erythema dose (MED) testing.5

MED testing exposes a small area of normal skin to a range of UVB doses. It is performed with a handheld unit that is calibrated in a factory or by an in-house physicist. The patient’s skin is then examined 24 hours later to evaluate the erythema responses to the different strengths of UVB exposure (Figure 5.1). The starting dose of phototherapy is 70% of the dose that gives the mildest visible erythema.

The MED device allows for a more accurate starting dose, which in turn can reduce the number of treatments needed to obtain the best outcome.7 Ensuring that all team members measure erythema in the same way, using the same technique, is critical. The UV outputs from both the MED device and UV machine must correspond, so they must be calibrated at the same time. If they are not, the MED will not reflect the dose given by the UV machine, with potentially hazardous consequences. Currently, MED testing using UVA doses is unavailable in a handheld unit.

Patient support and education. Phototherapy nurses see patients on a regular basis (at least twice a week during treatment) and are therefore in an excellent position to provide health-promoting advice and psychological support. Chronic skin conditions can have

Figure 5.1 (a) The MED device is held lightly but firmly on the selected area of skin. It switches off automatically at the end of the exposure time. (b) 24 hours later, the skin is examined, and the MED is calculated. Reproduced courtesy of Dr Jonathan Batchelor, University of Nottingham, UK.

a significant effect on patients’ quality of life, affecting their mood, sleep patterns and relationships. However, the psychological impact of the disease is often overlooked and not addressed during short consultation times with clinicians. The phototherapy unit provides an environment in which this can be addressed and the phototherapy nurse can provide support, including signposting to support groups where appropriate.

The rapport built between nurse and patient during treatment can also facilitate discussion of important lifestyle issues, such as stopping smoking, reducing alcohol consumption and losing weight, enabling appropriate advice to be given.

Monitoring patient outcomes is a good way of assessing the effect of treatment on patients and can help to determine whether they need further therapeutic interventions, such as biological therapies. Specific disease assessment tools such as the Psoriasis Area and Severity Index (PASI) and Eczema Area and Severity Index (EASI) should be used at the beginning, during and end of treatment. In addition to helping determine appropriate subsequent treatment for individual patients, the information obtained from these types of tools helps to inform audit data (see below). See Chapter 6 for further details of the EASI and PASI (pages 96–7).

Patient photos can also be very useful for monitoring progress and can help to reassure patients that the severity of disease has reduced since the start of treatment.

Quality of life should also be assessed, as patients with skin conditions may require additional psychological support. The Dermatology Life Quality Index (DLQI) is a validated questionnaire with which patients can self-assess the impact of their skin problem on different aspects of their daily life.8 See Chapter 6 for further details of the DLQI (see page 99).

Review of service

The BAD has a set of audit criteria that can be used to monitor standards within phototherapy units.9 The criteria cover referral and patient assessment, patient information and consent, staff training and education, clinical management and monitoring, equipment and facilities, clinical governance and audit, discharge protocol and skin cancer surveillance. These standards can help to ensure that existing services provide safe and effective delivery of care to patients and that new services are set up in a way that ensures patient safety and optimises treatment.

In addition to the BAD’s standards, the following audit measures can be used to monitor the effectiveness of phototherapy services.

• Audit DLQI/PASI scores before and after treatment.

• Number of patients seen.

• Waiting list times (are these within guidelines?).

• Patient satisfaction issues, such as:

– Were appointment times satisfactory?

– Did patients have to wait at appointment times or were they seen promptly?

– Was privacy maintained?

– Did the treatment help?

– Were all questions answered?

Staff training and education. Phototherapy services must have sufficient, appropriately registered, qualified and experienced medical, nursing and other clinical and non-clinical staff to provide appropriate services in all respects at all times. The BAD criteria recommend that all phototherapists should undergo some form of

educational activity in phototherapy at least once a year, including attending a recognised course at least once every 3 years. In addition, all phototherapy staff must have an annual appraisal and a personal development plan for their continuing professional development.

Equipment and facilities. The treatment room should be kept at 16–25oC. There should be adequate spacing for ease of access to phototherapy machines (Figure 5.2), and there needs to be enough space for the patient to undress and dress with privacy (with assistance if required), either with a curtained area (with disposable curtains) or a cubicle. Indeed, the patient’s privacy and dignity should be maintained at all times through the effective use of screens, blankets and appropriate clothing.

There should be adequate air conditioning and ventilation above machines. All equipment must be regularly calibrated and checked for electrical safety. The bulbs in phototherapy cabins are fitted with acrylic or glass guards as standard to prevent direct contact.

Using equipment safely. Accurate recording of exposure measurements facilitates comparison of results between phototherapy centres and assists in the safe transfer of patients between units. Machines must be cleaned in between patients, and their output should be checked and documented each morning before patient use.

(a)

Figure 5.2 (a) A UVB cabinet, used to treat patients with moderate-to-severe psoriasis. (b) A UVA unit used to treat psoriasis or eczema of the hands and feet; reproduced courtesy of Norfolk and Norwich University Hospitals.

Staff need to work at a distance from the machines when they are in use and occupational exposure to UV radiation must be assessed and kept below recommended limits.9

Patient safety is paramount and includes ensuring that they:

• can stand unaided during treatment, as the handles inside the machine are not weight-bearing

• stand in the same position for each treatment session

• do not take anything into the machine with them

• stand still during treatment (some machines have a sensor that cuts power when movement is detected)

• wear goggles to prevent future cataracts; if the eye area needs to be treated then the patient must keep their eyes closed

• wear dark-coloured underwear to protect their genitals (men).

Career progression: next steps

For some nurses, providing phototherapy for patients with skin diseases will be the only contact they have with dermatology patients, while for others it will form just part of their role as a dermatology nurse. As discussed above, all staff must have an annual review that includes a phototherapy update, during which specific targets for knowledge and skill acquisition should be set, including a good underpinning knowledge of the dermatological conditions treated with phototherapy and all relevant therapeutic interventions.

To progress to band 6 in phototherapy, consider the following:

• Complete a recognised course in phototherapy: for example, BDNG e-learning (visit the BDNG website for more information) or one of the phototherapy courses provided by Newport Phototherapy Training.10 The BDNG also has a photodermatology subgroup offering contact, support and training. Photonet also provides an online module and yearly study days.3

• Develop the leadership skills and confidence required to take on increased responsibility within the team: for example, independently manage the phototherapy unit on a day-to-day basis and supervise other members of staff.

• Manage the smooth running of the phototherapy unit: for example, arrange machine maintenance, monitor infection control strategies, undertake audits and organise patient satisfaction questionnaires.

• Gain knowledge of the different dermatological conditions and how UV light affects them. Understand what can be considered a satisfactory response to a course of phototherapy and when to feel confident to stop treatment (that is, when it is no longer therapeutic).

To progress to band 7 in phototherapy consider the following:

• Gain a recognised qualification, such as an MSc in dermatology. Modules within the MSc can be used independently to demonstrate an underpinning knowledge and evidence base for treatments and conditions.

• Qualify as an independent nurse prescriber so that necessary treatments (particularly topical therapies) can be prescribed for patients undergoing phototherapy in a timely manner.

• Develop further managerial skills by leading audits and managing staffing within the phototherapy unit.

• Lead clinical governance within phototherapy, ensuring appropriate developmental opportunities such as educational meetings, learning from adverse events and discussing issues raised from incident reports.

The future

Phototherapy is an effective treatment modality, but since the introduction of biological drugs there have been concerns that it may become a less relevant treatment option. The first biologics arrived 20 years ago, yet phototherapy still has a significant place in the patient treatment pathway. Indeed, it may be an important treatment step before patients are given systemic or biological treatments. Some data also suggest that implementing and/or widening phototherapy services may lead to significant cost savings, making it an attractive treatment option for healthcare providers.11

Key points – phototherapy

• Phototherapy is a potentially dangerous environment, so clear standards and procedures need to be in place to ensure the safety of staff and patients.

• There is clear career progression within phototherapy, which involves the development of clinical, leadership and managerial skills.

• For phototherapy to be delivered safely, nurses must have signed-off competencies accompanied by an annual performance review that includes a phototherapy update.

• During a course of phototherapy, nurses have regular and frequent contact with patients. This facilitates patient education and support for issues directly related to their skin condition but also other lifestyle and mental health wellbeing issues.

• Auditing against clear standards helps to ensure safety and a high quality of care within the phototherapy department.

References and resources

1. Rathod DG, Muneer H, Masood S. Phototherapy. In: StatPearls [Internet]. StatPearls Publishing, 2022. www.ncbi. nlm.nih.gov/books/NBK563140, last accessed 23 March 2022.

2. Hönigsmann H. History of phototherapy in dermatology. Photochem Photobiol Sci 2013; 12:16–21.

3. Photonet. National Managed Clinical Network for Phototherapy in Scotland. Turas e-Learning Course. Photonet, 2022. www.photonet.scot. nhs.uk/elearning-course, last accessed 23 March 2022.

4. Ca meron H, Yule S, Dawe RS et al. Review of an established UK home phototherapy service 1998–2011: improving access to a cost-effective treatment for chronic skin disease. Public Health 2014;128:317–24.

5. Pa lmer R, Garibaldinos T, Hawk J [updated by Sarkany R]. MPD and MED testing. In: Phototherapy Guidelines St John’s Institute of Dermatology, 2009:5. www.phototherapysupport.net/ wp-content/uploads/2020/01/ Phototherapy-Guidelines.pdf, last accessed 24 June 2022.

6. DermNet NZ. Fitzpatrick Skin P rototype. www.dermnetnz.org/ topics/skin-phototype, last accessed 24 June 2022.

7. He ckman CJ, Chandler R, Kloss JD et al. Minimal erythema dose (MED) testing. J Vis Exp 2013;(75):e50175.

8. Fi nlay AY, Khan GK. Dermatology Life Quality Index (DLQI): a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210–16.

9. Br itish Association of Dermatologists. Service Guidance and Standards for Phototherapy Units. British Association of Dermatologists, 2016. https://cdn.bad.org.uk/ uploads/2021/12/29200202/ Phototherapy-Service-Guidance -and-Standards-20193.pdf, last accessed 12 July 2022.

Further reading and resources

Campbell J. Safe and effective use of phototherapy and photochemotherapy in the treatment of psoriasis. Br J Nurs 2020;29:547–52.

DermaTools. Comprehensive digital tools to monitor dermatologic conditions. Developed by dermatologists for dermatologists and patients. www.dermavalue.com

10. Newport Phototherapy Training. Courses for Healthcare Professionals. Newport Phototherapy Training, 2022. www.newportphototherapy training.co.uk, last accessed 4 April 2022.

11. Fo erster J, Dawe R. Phototherapy achieves significant cost savings by the delay of drug‐based treatment in psoriasis. Photodermatol Photoimmunol Photomed 2020;36:90–6.

Menter A, Smith C, Barker J et al. Phototherapy and photochemotherapy. In: Fast Facts: Psoriasis, 4th edn. S. Karger Publishers Ltd, 2014:65–73.

The South East of England Phototherapy Network. www.phototherapysupport.net

Medicines management has long been part of the registered nurse’s role. In recent years, policy changes, in particular the introduction of independent prescribing, have facilitated greater nursing involvement with the initiation and monitoring of dermatological drugs, including biologics.

Nursing role

Nurse-led systemic drug monitoring clinics can enhance care delivery, reduce existing waiting lists and free up medical consultant time, while maintaining an efficient, high quality service. Nurses can also add extra value by introducing individualised health promotion to patients during routine monitoring appointments.

Scope of practice. When determining the appropriate competence level for a nurse working with systemic medicines within the NHS, either initiating, monitoring or both, it is critical to take their banding into account. Private healthcare providers should also ensure that job descriptions are aligned with BDNG role descriptors. The BDNG role descriptors indicate the appropriate level of responsibility for each band within a dermatology setting (see page 12).1 It is recommended that the entry point for systemic monitoring should be band 6, with greater levels of responsibility and independent practice at bands 7 and 8. Band 5 nurses should not be involved in the monitoring of systemic therapy. Table 6.1 demonstrates the roles and responsibilities of dermatology nurses in the monitoring of systemic therapies according to nursing band.

The patient care setting. Monitoring of systemic therapies can take place in secondary or primary care using a shared-care model. Models of care vary between hospitals. Some will have a separate monitoring list that runs alongside a clinician list; the clinician can be approached during the clinic for further advice or guidance. Others will have drug monitoring as its own separate activity.

TABLE 6.1

Roles and responsibilities of dermatology nurses in systemic therapy monitoring

BandClinical skills

5• Not recommended

6

• Runs disease- or therapy-focused nurse-led follow-up clinics with an approved protocol (e.g. for isotretinoin or biologics)

• Does not initiate or change treatment

7

• After confirmed treatment decision by relevant clinician, commences and monitors systemic immunosuppressant therapies (e.g. methotrexate, azathioprine, dapsone, ciclosporin)

• Orders, interprets and acts on blood tests related to the commencement and monitoring of these therapies

• Follows written protocols that include strict parameters for dose changes

8+

• Independently initiates therapies in accordance with local guidance

• Monitors more complex cases

• Takes greater autonomy and clinical responsibility in the care of patients

• May clinically supervise/line manage nurses at lower grades who are involved in monitoring systemic therapies

New systemic therapy monitoring services must be set up to meet local patient needs but the following considerations will be relevant to all services.

• Availability of support in case of a medical emergency or clinical query.

• Estimation of the number of patients requiring monitoring now and in the future, as this will affect how the service is staffed and the planning for future staff requirements.

• The proportion of patients who can be seen virtually at follow up and those who will need to have a face-to-face appointment. If a service is to be delivered remotely, consideration must be given to

how investigations will be carried out and how patients will access prescriptions.

• Consideration of how the liaison between primary and secondary care will work. Will there be shared-care monitoring and, if so, how will this work?

• Awareness of any local restrictions on independent prescribers, as these will limit what they can prescribe.

• A schedule for audit, so that regular monitoring of standards is considered from the outset.

Competence levels

The level of autonomy that nurses have in monitoring patients on systemic therapy will depend on individual service needs. Some nurses will be allowed to work completely autonomously, while others may be required to work under the direction of a medical clinician. It is important that all members of the MDT agree on the scope of practice for the nurse (see above) and that the competencies devised reflect this. Factors that will affect levels of autonomy may include whether the service is secondary or tertiary care and how prescriptive the Clinical Commissioning Group is with regards to choice of treatment (for example, treatment pathways that list biological drugs in order of prescribing preference).

Initiation of treatment may also incur different responsibilities within different settings. It is important when devising any competencies to be explicit about the patient pathway. For example, in some settings the clinician may ask the nurse to initiate a biologic with the nurse autonomously choosing the biologic and completing all the screening. In other settings, the nurse may be asked to initiate a named therapy and complete a brief screening only.

Before developing a competency framework, it is recommended that the MDT work together to devise an overarching protocol that considers the following.

• Clarity of the scope and purpose of the clinic (for example, will nurses be initiating treatment or only monitoring it?).

• Referral processes (both within and out of the clinic) and inclusion/exclusion criteria for patients (that is, which patients will be considered appropriate [or not] for the monitoring service).

• How correspondence, such as letters, from the clinic will be managed.

• How patients will be discharged and how patients who do not attend appointments will be managed.

• Which drug-specific monitoring protocols will be used (accessing, for example, BAD and NICE guidelines).

All of the above should have clear review dates.

Setting competencies. Once protocols are finalised, competencies can be developed. Competencies should, as a minimum, include topics such as patient assessment, drug monitoring and clinical decision-making, as well as the ability to implement any of the standardised scoring systems used for drugs under NICE guidance. Table 6.2 gives some examples of practical and theoretical competencies for drug monitoring, each of which can be attained at levels 0–5 (see Table 1.2). It should be noted, however, that level 3 is the minimum for all competencies for a nurse to practise independently, and in most services the nurse would be expected to achieve level 4/5 within 6 months.

TABLE 6.2

Example of competency framework for drug monitoring

Practical competencies

• Locates and accesses relevant drug monitoring protocols, guidance and SOP

• Locates drug monitoring referral and confirms appropriateness (i.e. the referral source/procedure has been followed correctly according to clinical guidelines)

• Fulfils full screening criteria and ensures results are satisfactory; explicitly notes any omissions before starting therapy

• Confirms treatment has been satisfactorily initiated

• Recognises significant out-of-range screening results and discusses with the referring clinician

• Confirms the referring clinician’s instructions with regards to starting dose, dose escalation and monitoring requirements

• Confirms prescriber has supplied a valid prescription and pharmacy has dispensed to the patient

TABLE

CONTINUED

Example of competency framework for drug monitoring Practical competencies (CONTD)

• Knows how the patient will be tracked for follow ups, including remote monitoring

• Accesses and reviews blood test results

• Accurately orders blood tests for any given monitoring situation

• Understands the implications of abnormalities in blood test results (including trends over time) and knows how to escalate appropriately

• Assesses and monitors side effects

• Instructs patient to take or stop taking their medication based on blood test results and clinical status (knows if they are systemically well)

• Completes accurate documentation, including standardised disease severity scoring systems

• Sends accurate letters within the prescribed timeframe

• Demonstrates actions needed when patient is non-adherent to drug monitoring

Theoretical competencies

• Can discuss rationale for drug monitoring

• Can give examples of inappropriate referrals

• Understands the importance of a nurse-led monitoring service

• Can locate and is familiar with all relevant SOP and protocols

• Has appropriate knowledge of drug parameters and significance of abnormal blood results and the rationale for highlighting in a timely manner

• Is aware of their understanding/limitations by providing examples

• Can give scenarios of when a patient should be asked to stop taking their medication or seek urgent medical attention

Note: each of the competencies described here can be attained at levels 0–5 (see Table 1.2).

Core knowledge domains

Patient assessment and screening should be tailored to the drug that has been prescribed. For patients starting biological therapy, a prebiologic treatment checklist is available on the BAD’s Biologic Interventions Register (BADBIR) website.2 Investigations should be appropriate to the drug being monitored, with particular attention given if a patient is switching drugs. Ordering unnecessary tests can cause expense and delays in treatment. Appropriate tests for screening should be agreed by the MDT, with reference to the relevant drug protocol.

It is envisaged that band 6 nurses involved in screening and monitoring will work in monitoring clinics for specific therapeutics that have well-established monitoring pathways (for example, isotretinoin). Band 7 and 8 nurses are better placed for more autonomous practice, such as identifying tuberculosis risk factors or highlighting potential contraindications to treatment after a clinician has completed basic screening (for example, if a woman of childbearing potential about to start methotrexate does not wish to use contraception).

Completion of the advanced assessment course is recommended as it allows the nurse to be fully autonomous in patient assessment and screening. This is particularly aligned with the BDNG role descriptors at bands 7 and 8, and band 7 nurses should consider completing the course if they have not previously done so.

When recording severity scores for patients on drugs that require percentage improvements at set time points, it may be worth recording the individual components of the score at baseline and the efficacy time point to determine which elements of the score have not reached the required improvement.

Monitoring. Thorough knowledge of the drug being monitored, including its mechanism of action and relevant blood parameters, is essential. Specific knowledge may be required for certain drugs: for example, mood monitoring for isotretinoin and blood pressure monitoring for ciclosporin. Nurses should also know how to access further information, such as drug interactions and side effects, in a timely manner. For remote monitoring, nurses must develop the skills to conduct effective virtual consultations. Resources for virtual consultations have, since the COVID-19 pandemic, often been

developed at a local level, but guidance is also available on the BAD and devolved NHS websites.3,4

Regardless of the nurse’s band there should be a clear pathway for escalation of queries. It is recommended that all pathways should ensure that nurses are not held back from clinical activities by tasks that can be completed by an administrator, such as collecting blood test results.

Patient education. Routine monitoring appointments are a valuable opportunity for holistic patient education. Useful topics are discussed below.

Comorbidities. The health implications of any comorbidities related to the patient’s condition should be discussed and lifestyle advice offered where appropriate. Having information about local services that support lifestyle changes, such as smoking cessation and weight loss, can enhance the nurse’s ability to support healthy behavioural changes. Motivational interviewing can also help to support behavioural changes.5 Another initiative that is well suited to a dermatology population is Making Every Contact Count, which is supported by NHS England.6

Mental health. Skin disease can be hugely impactful on a patient’s mental health, as discussed in the 2020 report of the All-Party Parliamentary Group on Skin.7 The DLQI (see page 99) only looks at the effect of skin disease on quality of life and does not assess depression and anxiety.8 Therefore, mental health screening should also include use of the Patient Health Questionnaire-9 (PHQ-9; the major depressive disorder module of the full PHQ) and the Generalised Anxiety Disorder assessment (GAD-7).

It is worth becoming familiar with available primary care services, such as cognitive behavioural therapy (along with the process of referral to local therapists) and programmes such as Improving Access to Psychological Therapies.9 Patients can self-refer, but it is worth considering helping the patient to complete the referral in clinic.

Vaccination. There is a unique opportunity to ensure patients are fully vaccinated with all applicable vaccines before they start treatment, as systemics and biologics can affect vaccine responses; indeed, some vaccines are contraindicated without a long washout once treatment is started. Information regarding coronavirus

(COVID-19) vaccines is continually being revised, so nurses should be careful to access the most up-to-date information at www.gov.uk. A good source of information regarding vaccines is the Green Book. 10

Health literacy. The National Literacy Trust estimates that 7.1 million people have poor literacy skills.11 Nurses should ensure that patients fully comprehend any information they are given, especially if poor literacy means written information is not helpful.

Storing medicines. It is important to ensure the patient knows how to store medication properly and how to avoid spoiling their dose prior to use. Biologics are often delivered by homecare companies. If this is the case, realistic timelines for processing and delivering the prescription must be built into the model.

Planning pregnancy. Conception plans must be regularly discussed with patients to allow for treatment adjustments and specialist advice to be sought in a timely manner.

Cancer screening. Patients’ participation in relevant cancer screening programmes should be confirmed at regular intervals. In the UK, programmes are available for cervical, breast and bowel screening.12

Independent prescribing is a well-established practice in dermatological care. It is advisable, but not essential, that band 6 nurses working in a drug monitoring clinic be independent prescribers; nurses of band 7 and 8 competence should be independent prescribers.1 If a nurse working in a monitoring clinic is not an independent prescriber, strategies must be put in place to access new prescriptions in a timely manner: for example, through the use of a patient group direction.

The scope of independent prescribing will be decided locally and should be considered when establishing a monitoring clinic. As per the Royal Pharmaceutical Society’s Competency Framework for all Prescribers,13 nurses should only ever prescribe within their scope of practice (that is, what they are competent to prescribe). However, as competencies are achieved this scope may expand.

Disease severity tools. Some systemic drugs used to treat skin conditions are subject to NICE guidance. This means that they can only be prescribed for patients that meet certain criteria. These criteria

usually involve the use of validated disease severity scoring tools, such as the EASI14 and PASI.15

Both the EASI and PASI recognise that their respective conditions can vary in appearance and extent on different body parts (Figure 6.1). Therefore, these screening tools involve assessment of four body regions – the head and neck, upper limbs (hands and arms), trunk (chest, abdomen and back), and lower limbs (buttocks, thighs, legs and feet) – which are examined and scored separately before weighting the score in the final calculation. Both the EASI and PASI require grading of common signs and symptoms of the disease as well as calculating the body area affected. Scoring is best performed in an area in which natural lighting is available.

The EASI is used for patients with eczema. Examples are available online.16,17 The EASI assesses the severity and extent of eczema according to appearance (erythema, oedema/papulation, excoriation and lichenification) and the amount of body area covered for each of the four body regions described above. The range of absolute EASI scores is 0–72, with 0 indicating no eczema and a score greater than 21 indicating severe eczema.18 No specific baseline score is required to start treatment, but a 50% EASI improvement is required at certain time points for treatments such as dupilumab and baricitinib to be continued.

The PASI is a quantitative rating score that measures the severity and extent of psoriatic lesions according to appearance (erythema, induration/thickness and scaling) and the amount of body area covered for each of the four body regions described above. Examples are available online.19,20 The range of absolute PASI scores is 0–72, with 0 indicating no psoriasis and a score greater than 10 indicating severe psoriasis. Patients with psoriasis must have a PASI score of at least 10 before biological therapy is considered and must demonstrate 50% improvement or more by a given time point for the drug to be continued. For example, if a patient starts adalimumab with a PASI score of 15, by week 16 their PASI score must be 6 or lower to continue treatment in accordance with NICE guidance.

Patients with high impact site disease (psoriasis on sensitive areas like the face and genitals, which can have a huge impact on quality of

(a)

(b)

Figure 6.1 The appearance and extent of (a) eczema and (b) psoriasis varies on different body regions in different people.

life) struggle to access biological therapy, as it is hard for their psoriasis to score 10 on the PASI. Some dermatology services now accept a modified version of the PASI, as the reduced cost of biosimilars has made targeted treatment a more attractive option in these patients.

BAD guidance for biologics supports the treatment of patients with severe psoriasis at localized sites that is associated with significant

Monitoring

functional impairment and/or high levels of distress, regardless of their PASI score.21

Training is essential to ensure effective use of these tools and to minimise inconsistencies when calculating disease severity. Local consensus can be maintained by regular team scoring of the same patient to ensure consistency within the service. Patients being reviewed in a secondary care setting for the first time may not be used to having their skin graded and examined in depth. It is always good practice to talk through planned procedures with patients and to ensure that their privacy and dignity are maintained, including offering a chaperone.

Post-inflammatory hyper- or hypopigmentation should never be scored as active disease for either scoring system. However, it is worth noting that these changes in skin colour can be as concerning to the patient as the skin condition itself, and patients should be warned of the possibility of skin colour changes when starting a new treatment.

Care should be taken that erythema is not underscored in skin of colour. In dark-skinned individuals, erythema can present as darkening of the skin, with redness visible only in those with severe or very severe disease (Figure 6.2). Any training in the use of the EASI/ PASI and other skin assessment tools should include images of the appearance of the disease in skin of colour.

Figure 6.2 Erythema on dark skin in a child with eczema.

Patient-oriented outcome measures can be used to assess the relationship between disease severity and health-related quality of life.

The DLQI. Patients should also be asked to complete the DLQI to ensure the impact of their condition on activities of daily living is captured. The DLQI comprises ten questions that patients can use to self-assess the effect of their skin problem on different aspects of their daily life.22 Examples are available online.23,24

The DLQI asks, over the last week:

• how itchy, sore, painful or stinging has your skin been?

• how embarrassed or self-conscious have you been because of your skin?

• how much has your skin interfered with you going shopping or looking after your home or garden?

• how much has your skin influenced the clothes you wear?

• how much has your skin affected any social or leisure activities?

• how much has your skin made it difficult for you to do any sport?

• has your skin prevented you from working or studying? If no, how much has your skin been a problem at work or studying?

• how much has your skin created problems with your partner or any of your close friends or relatives?

• how much has your skin caused any sexual difficulties?

• how much of a problem has the treatment for your skin been: for example, by making your home messy or by taking up time?

The patient assesses each of these questions as very much (3), a lot (2), a little (1) or not at all (0). The higher the total score the more the patient’s quality of life is impaired (0–1, no effect; 2–5, small effect; 6–10, moderate effect; 11–20, very large effect; 21–30, extremely large effect).

The DLQI also has a ‘not applicable’ option for each of the questions. If a patient replies ‘not applicable’ to more than a couple of questions it is a good idea to discuss their answers further. For example, it may be that they have scored ‘not applicable’ for how their skin disease impacts sport because they do not want to use communal changing rooms where their skin disease may be visible and, as a result, do not play any sport. If they say that they would use changing rooms and play sport if they did not have a skin disease, then they should consider changing their score to ‘very much’.

The POEM. For adults and children with eczema, the PatientOrientated Eczema Measure (POEM) can also be utilized as it focuses on the impact of eczema symptoms from the patient’s perspective, not just on objective disease severity.25 The POEM asks, over the last week, because of the eczema:

• on how many days has your/your child’s skin been itchy?

• on how many nights has your/your child’s sleep been disturbed?

• on how many days has your/your child’s skin been bleeding?

• on how many days has your/your child’s skin been weeping or oozing clear fluid?

• on how many days has your/your child’s skin been cracked?

• on how many days has your/your child’s skin been flaking?

• on how many days has your/your child’s skin felt dry or rough?

The patient, or patient’s parent, assesses each of these questions as no days (0), 1–2 days (1), 3–4 days (2), 5–6 days (3), or every day (4).

The higher the total score the greater the severity of the condition (0–2, clear or almost clear; 3–7, mild; 8–16, moderate; 17–24, severe; 25–28, very severe).26 As these scores are completed by the patient, it is advisable to ask them to complete them before or at the start of the consultation to ensure their answers are not affected by any actions during the visit.

Next steps

Courses and training. When developing the skills to work within systemic drug monitoring clinics, the following opportunities are available for professional development.

• Consider taking an independent prescribing and advanced assessment module, which can usually be accessed at local universities that run postgraduate nursing courses.

• Consider undertaking an MSc in clinical dermatology.

• Join the Biologics subgroup of the BDNG to access the plethora of resources.

• Attend relevant BDNG conference/study events.

• Register for events sponsored by pharmaceutical companies. These are often virtual, free to attend and scheduled at convenient times.

• Consider a preceptorship or shadowing at a centre of excellence.

Monitoring systemic therapies

Who to talk to. It is helpful to liaise with colleagues in immunemediated inflammatory disease departments as they will be using the same or similar drugs. Networking with colleagues in other dermatology departments can also be useful. Representatives of pharmaceutical companies can also be a useful source of information about specific drugs and homecare options.

Key points – monitoring systemic therapies

• Nurse-led systemic drug monitoring clinics can enhance care delivery, reduce waiting lists, free up medical consultant time and provide an opportunity for additional health promotion.

• All roles and responsibilities must be clearly aligned with the BDNG role descriptors; the entry level for systemic monitoring is band 6, with greater levels of responsibility and independent practice at bands 7 and 8.

• New systemic therapy services should be planned with capacity increases in mind.

• Take time to involve the whole MDT in ensuring robust protocols are developed for the effective and safe monitoring of patients, including scope of practice, referral and discharge processes, and appropriate administrative support to collect remote blood tests and field patient queries.

• Core knowledge domains include patient assessment and screening tailored to the drug that has been prescribed, knowledge of the drug being monitored (including its mechanism of action and relevant blood parameters), holistic patient education, and use of disease severity and quality of life assessment tools.

References and resources

1. British Association of D ermatologists 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/wpcontent/uploads/2020/08/ BAD-BDNG-RCN-NURSINGWORKSTREAM-A4LANDSCAPE-002.pdf, last accessed 1 February 2022.

2. Br itish Association of Dermatologists Biologic Interventions Register. Pre-Biologic Treatment Checklist. www.badbir.org/ Data/Clinicians/Resources/ PreBiologicChecklist.pdf, last accessed 4 April 2022.

3. Br itish Association of Dermatologists. Teledermatology. www.bad.org.uk/clinicalservices/teledermatology, last accessed 24 June 2022.

4. NH S England. Video Consulting with Your NHS: Guides for Patients, Staff and Trusts. NHS, 2022. www.england.nhs.uk/ publication/video-consultingwith-your-nhs-guides-forpatients-staff-and-trusts, last accessed 24 June 2022.

5. Ch isholm A, Nelson PA, Pearce CJ et al. Motivational interviewing-based training enhances clinicians’ skills and knowledge in psoriasis: findings from the Pso Well® study. Br J Dermatol 2016;176:677–86.

6. NH S Health Education England. Making Every Contact Count. www.making everycontactcount.co.uk, last accessed 1 February 2022.

7. Al l-Party Parliamentary Group on Skin. Mental Health and Skin Disease. All-Party Parliamentary Group on Skin, 2020. www.appgs.co.uk/publication/ mental-health-and-skindisease-2020.pdf, last accessed 12 July 2022.

8. Ca rdiff University. Quality of Life Questionnaires. Cardiff University School of Medicine, 2022. www.cardiff.ac.uk/ medicine/resources/qualityof-life-questionnaires, last accessed 12 July 2022.

9. NH S England. Adult Improving Access to Psychological Therapies Programme. www.england.nhs. uk/mental-health/adults/iapt, last accessed 1 February 2022.

10. G OV.UK. The Green Book. Information for Public Health Professionals on Immunisation www.gov.uk/government/ collections/immunisationagainst-infectious-disease-thegreen-book#the-green-book, last accessed 6 April 2022.

11. National Literacy Trust. What Do Adult Literacy Levels Mean? www.literacytrust.org.uk/ parents-and-families/adultliteracy/what-do-adult-literacylevels-mean, last accessed 1 February 2022.

12. NHS England. Screening and E arlier Diagnosis. www.england. nhs.uk/cancer/early-diagnosis/ screening-and-earlier-diagnosis, last accessed 4 April 2022.

13. Royal Pharmaceutical Society. A Competency Framework for all Prescribers. Royal Pharmaceutical Society of Great Britain, 2021. www.rpharms. com/resources/frameworks/ prescribers-competencyframework, last accessed 1 February 2022.

14. Ha nifin JM, Thurston M, Omoto M et al. The eczema area and severity index (EASI): assessment of reliability in atopic dermatitis. EASI Evaluator Group. Exp Dermatol 2001;10:11–18.

15. Fredriksson T, Pettersson U. Severe psoriasis – oral therapy with a new retinoid. Dermatologica 1978;157:238.

16. Ha rmonising Outcome Measures for Eczema (HOME). EASI for Clinical Signs. Centre of Evidence Based Dermatology, University of Nottingham. www.homeforeczema.org/ research/easi-for-clinical-signs. aspx, last accessed 4 April 2022.

17. D ermaTools. Electronic Eczema Area and Severity Index (eEASI) www.dermavalue.com/eEASI. html, last accessed 12 July 2022.

18. Leshem YA, Hajar T, Hanifin JM, Simpson EL. What the Eczema Area and Severity Index score tells us about the severity of atopic dermatitis: an interpretability study. Br J Dermatol 2015;172:1353–7.

19. Oa kley A. PASI Score. DermNet NZ, 2009. www.dermnetnz.org/ topics/pasi-score, last accessed 18 July 2022.

20. D ermaTools. Electronic Psoriasis Area Severity Index (ePASI). www.dermavalue.com/ePASI. html, last accessed 12 July 2022.

21. Sm ith CH, Yiu ZZN, Bale T et al. British Association of Dermatologists guidelines for biologic therapy for psoriasis 2020: a rapid update. Br J Dermatol 2020;183:628–37.

22. Fi nlay AY, Khan GK. Dermatology Life Quality Index (DLQI): a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210–16.

23. Ca rdiff University. Dermatology Life Quality Index (DLQI). Cardiff University School of Medicine, 2019. www.cardiff. ac.uk/medicine/resources/ quality-of-life-questionnaires/ dermatology-life-quality-index, last accessed 26 May 2022.

24. De rmaTools. Electronic Dermatology Life Quality Index (eDLQI). www.dermavalue.com/ eDLQI.html, last accessed 12 July 2022.

25. Charman C, Venn AJ, Williams HC. The patientoriented eczema measure: development and initial validation of a new tool for measuring atopic eczema severity from the patients’ perspective. Arch Dermatol 2004;140:1513–19.

26. Charman CR, Venn AJ, R avenscroft JC, Williams HC. Translating Patient-Oriented Eczema Measure (POEM) scores into clinical practice by suggesting severity strata derived using anchor-based methods. Br J Dermatol 2013; 169:1326–32.

Further reading and resources

British Association of Dermatologists Describing Erythema in Skin of Colour. www.bad.org.uk/education-training/ skin-of-colour-in-dermatologyeducation

Psoriasis. www.bad.org.uk/ healthcare-professionals/psoriasis

British Dermatological Nursing Group. Nurse Led Systemic Monitoring Clinics – Guidance on Setting up this Service. www.bdng.org.uk/wpcontent/uploads/2017/02/systemicmonitoringALL.pdf

DermNet NZ

EASI score. www.dermnetnz.org/ topics/easi-score

PASI score. www.dermnetnz.org/ topics/pasi-score

DermaTools. Comprehensive digital tools to monitor dermatologic conditions. Developed by dermatologists for dermatologists and patients. www.dermavalue.com

Harmonising Outcome Measures for Eczema (HOME). www.homeforeczema.org

Le Roux E, Schofield J. Setting up remote consultations for people with skin conditions: ensuring patients are seen in the right place at the right time. Dermatol Nurs 2021;20(3).

NHS England. Find an NHS Psychological Therapies Service (IAPT). www.nhs.uk/service-search/ mental-health/find-a-psychologicaltherapies-service

Royal College of Nursing. Medicines Management. An Overview for Nursing. Royal College of Nursing, 2020. www.rcn.org.uk/ProfessionalDevelopment/publications/pub009018

Wakelin SH, Maibach HI, Archer CB, eds. Handbook of Systemic Drug Treatment in Dermatology, 2nd edn. CRC Press, 2015.

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

Finger-tip measurements

1 finger-tip length = 0.5 g

2 finger-tip lengths = 1 g

1 pump unit = 1 g

One adult finger-tip unit

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

gOne arm

Trunk (front and back)

g

One leg 1.0 g

g

Face and neck

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. Nu rsing & 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. C lothier 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. Br itish 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-BDNGRCN-NURSING-WORKSTREAMA4-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-steroidsSep-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. La ming 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

limb management

Melanie Sutherland RN MSc

With over 2000 diagnoses, dermatology is a field of medicine in which specialisation is often required. Specialising in lower limb dermatology involves seeing patients who have been referred with various lower limb conditions, including those with leg ulcers that have failed to heal and ‘red legs’ dermatoses.

Nurses generally have more exposure to, and experience with, wound care and dressings than doctors. For this reason, dermatology nurses are often best placed to provide patients with ongoing treatment and prevention advice about lower limb conditions. Indeed, patients can benefit hugely from seeing an experienced specialist nurse with a wide range of knowledge and training on lower limb management. Managing complex problems related to the lower leg can significantly improve physical and psychological outcomes for patients.

Often, patients have had inappropriate treatment with no explanation of the cause, so being able to spend time educating the patient and leading them on an appropriate care pathway is hugely satisfying and rewarding.

The nursing role

Scope of practice. When developing new roles in specialist lower limb services, the BDNG role descriptors should be used as a guide to establish roles and responsibilities at different banding levels (see page 12).1 These can range from a staff nurse at band 5 to the highly specialist responsibilities of an advanced practitioner (band 8a) or nurse consultant (band 8b). The difference between these bandings will be determined by specific responsibilities, the extent of independent practice and the competencies required to successfully deliver care at that level. As with all dermatological nursing roles, the higher the band the greater the level of independent decision-making around patient diagnosis and treatment.

Table 8.1 summarises the technical tasks that can be undertaken at specific band levels. The nurse must demonstrate competence before working independently; this will include proving they have underpinning knowledge in each area. Competency frameworks must be developed alongside Trust protocols.

The patient care setting. Patients are usually referred from community care to specialist dermatology services when a diagnosis is needed or when advice and a management plan is required for difficult-to-manage cases. Patients with lower limb conditions are often initially assessed by a dermatology nurse with advanced skills to ensure an accurate diagnosis as well as advising on skin care, dressings and compression therapy. Patients with more complex conditions may require joint review with the medical team, particularly if the patient requires systemic treatment or management of an underlying condition.

The key to successful lower limb services is joint working between primary and secondary care so that once specialist services have a clear diagnosis and management plan established, care is transferred back to the community.

Competencies

By band. The role of band 5/6 nurses is to provide patient education and skin care demonstrations, assess wounds, calculate ankle brachial pressure index (ABPI) and measure for appropriate compression therapy. Nurses at this level must be able to recognise the more common causes of ulceration – venous or arterial disease – and know when to flag this to a dermatology advanced nurse or doctor for further investigations when an ulcer does not seem to be responding as expected. Nurses at the higher bands (7/8) must be able to recognise and diagnose the causes of lower limb problems in addition to the roles required for the lower bands. Underpinning knowledge should include other ulcer aetiologies beyond venous/ arterial disease.

Advanced clinical skills. Appropriate clinical supervision must always be available, particularly as the dermatology nurse takes on more advanced roles in lower limb management. As medical colleagues rarely specialise in this field it may be that, for some aspects of the role, clinical supervision will need to be provided by senior nursing colleagues. Those wishing to develop specific technical skills, for example undertaking biopsies, should follow the guidance provided in Chapter 4 on skin surgery.

Advanced practice within the field of lower limb management can have huge benefits for patients, helping to ensure continuity of care and access to clear and well-designed patient pathways. Being able to offer diagnostic skills (including biopsy) and prescribe appropriate therapies (for example, antibiotics or topical preparations) will shorten the patient pathway and ensure treatment is promptly provided. Skin biopsies are usually undertaken to rule out or diagnose malignancies or other complex conditions such as vasculitis. It is important to be able to recognise when a skin biopsy is required, as unnecessary biopsies can further lengthen the patient pathway with risk of infection and slowed healing.

Patient education and support are key roles for the dermatology nurse. Lower limb conditions are usually chronic in nature and require long-term care and ongoing review. To facilitate effective patient education, consultation and communication skills are vital so that patients understand the fundamentals of their condition and what they need to do to help manage it. Developing an appropriate management plan must take into account patient abilities and preferences in order to optimise patient outcomes.

Often patients are jointly managed with community nurses; twoway communication channels need to be clearly established so that treatment plans can be shared. Patient passports can be useful tools to enable effective communication between primary and secondary care.2 Patient passports contain useful information that allows communication between different services, enables the patient to take control and encourages self-management. Passports usually include the patient’s details, contact details for district nurses or the leg ulcer clinic, aetiology of the leg ulcer, assessment details, and current and previously prescribed treatments. Key issues to discuss with patients are shown in Table 8.2.

Common lower limb conditions

Around two-thirds of wounds treated by the NHS are on the lower legs.3 Patients requiring lower limb wound care are primarily managed in community care settings and referred, as required, to specialist services in secondary care, such as vascular or

Key education points to discuss with patients

• Basic description of the condition

• Skin care: washing, drying and use of topical products (e.g. emollients and topical steroids)

• Importance of elevation

• Passive foot exercises

• Importance of compression therapy

• General lifestyle advice (e.g. weight management, stopping smoking)

• When and how to seek further support

dermatology. There are numerous lower limb conditions; four of the most common are leg ulcers, cellulitis, red legs dermatoses and lymphoedema (Figure 8.1).

Leg ulcers. A leg ulcer is classified as a break in the skin, generally on a lower limb, which has not healed within 2 weeks;4 60–80% of leg ulcers are due to venous disease.5 Arterial ulcers or those of mixed aetiology are less common. Correct diagnosis of a leg ulcer can be challenging, so an HNA should be made. Indeed, anyone presenting with a wound on a lower limb that has failed to heal within 2 weeks should have a comprehensive assessment followed by a suitable treatment plan (see Assessment, page 130).6 Manchester University NHS Foundation Trust has published a useful example of a local leg ulcer pathway to assist with assessment and treatment decisions depending on clinical presentation. This has been adopted as part of NICE’s medical technology guidance for treating diabetic foot ulcers and leg ulcers.7,8

Acute or chronic inflammatory lower limb conditions, such as cellulitis, red legs dermatoses and lymphoedema, are also seen in specialist dermatology clinics. There is significant overlap in the management of these conditions. Dermatology nurses with training and skills in both wound care and oedema management, as well as experience with skin conditions, can provide huge benefits to patient outcomes.

Figure 8.1 Examples of lower limb conditions managed by dermatology nurses: (a) leg ulcer; (b) bilateral red legs dermatosis, seen here with chronic oedema; (c) cellulitis; (d) lymphoedema and fungal infection; (e) venous eczema. Photographs (b) to (e) reproduced courtesy of Medical Illustration, Norfolk and Norwich University Hospital.

Cellulitis. The Clinical Resource Efficiency Support Team (CREST), set up in 1988 to promote clinical efficiency in the health service in Northern Ireland, provides the most recent guidelines on the management of cellulitis in adults in the UK.9 Cellulitis commonly occurs in the legs and is an acute bacterial skin infection that spreads rapidly if not treated.10 It develops following failure of skin integrity after trauma, surgery, insect bites or tinea infection, and often presents in patients with existing skin conditions such as eczema, psoriasis and lymphoedema. Patients can be successfully treated by their primary

care provider with oral antibiotics if treatment is started early; however, treatment delays often result in the cellulitis becoming progressively worse, requiring hospital admission for intravenous antibiotics.

Red legs dermatoses, such as lipodermatosclerosis and different types of eczema/dermatitis, are often misdiagnosed and treated as cellulitis. An audit of one UK service following transfer of care of patients with lower limb cellulitis from primary to secondary care found that nearly half of the patients had been misdiagnosed as having cellulitis and treated with unnecessary antibiotics.11 The rising incidence of antibiotic resistance through overprescribing12 emphasises the importance of an accurate diagnosis for red legs. The British Lymphology Society has developed a red leg pathway to ensure correct identification of the cause of red legs and to reduce incorrect diagnosis leading to overprescribing of antibiotics for cellulitis.13

Being able to make the distinction between red legs caused by a dermatological condition and those caused by cellulitis is a critical diagnostic skill. The key differentials are outlined in Table 8.3 (also see Figure 8.1).

Lymphoedema. Some dermatology services may also have a lymphoedema service. Often red legs or recurrent episodes of cellulitis can contribute to developing lymphoedema. Lymphoedema is a chronic incurable oedema caused by failure of the lymphatic system.14 This failure can have primary or secondary causes. Primary lymphoedema is a genetic disorder that develops from birth or later in life. It can occur anywhere in the body. Secondary lymphoedema is related to damage to the lymphatic system caused by cancer treatment, trauma, infections, immobility, obesity or venous disease. It is important to consider why a patient may have oedema in the limb when assessing the lower legs. Patients should be referred to a lymphoedema service if ongoing management is required.

Differential diagnosis of cellulitis and venous eczema

featureCellulitis

Symptoms• Unilateral limb erythema

Pyrexia

Not itchy

Painful

Feels unwell

Nausea

Signs• Spreading erythema

Lymphangitis may be present

Hot to touch

Blistering

History

Fast onset

Present for a day or a few days

Venous eczema*

Bilateral limb erythema but can present worse on one leg

Apyrexia

Itchiness

Tender ness

Fluctuating erythema

Crustiness

Weeping

Warm to touch

Present for months or years

Little or no response to antibiotic therapy

History of DVT

Varicose veins

Portal of entry

Sometimes unknown but common entry points include tinea pedis, ulceration, insect bites

Investigations• Blood tests – raised WBC and CRP

Blood cultures – often negative

Skin swabs can be helpful but sometimes negative growth

Skin scrapings and nail clippings to confirm fungal infections

Not applicable

Blood tests and blood cultures –normal

Skin swabs – often Staphylococcus aureus

known as varicose, gravitational or stasis eczema. CRP, C-reactive protein; DVT, deep vein thrombosis; WBC, white blood cell count.

More complex lower limb conditions

As discussed above, most patients with lower limb conditions are cared for in the community. However, a small number of patients will require referral to secondary care for more complex and ongoing management under the care of a dermatologist (Figure 8.2). For example, patients with a confirmed diagnosis of skin cancer, having first presented with a non-healing leg ulcer, will revert to a skin cancer pathway. They may require a surgical procedure or non-surgical treatments, depending on the type of skin cancer (see Chapter 3). In addition, conditions such as pyoderma gangrenosum or vasculitic ulcerations will often require more complex management involving an MDT approach, which may include systemic medications requiring ongoing review (see Chapter 6).

Assessment

The importance of an HNA cannot be overemphasised as it enables the dermatology nurse to support the patient, ensures all aspects of care are considered and improves patient outcomes. ABPI is a fundamental part of the HNA and can improve patient outcomes as well as reducing costs; however, it is not performed widely enough.15

Table 8.4 outlines the key elements of an HNA. Assessment must be undertaken in a suitable clinic environment. This should be a dedicated space with an appropriate couch, the height of which can be adjusted, facilities to wash lower limbs and access to appropriate paperwork, assessment tools, topical treatments and compression bandages.

Next steps

As a dermatology nurse wanting to specialise in this field, skills and knowledge related to general dermatology are a key starting point: for example, how to manage chronic inflammatory dermatoses. Next steps are to develop the relevant specialised knowledge base along

Figure 8.2 Examples of conditions that require more complex management involving an MDT approach: (a) Marjolin’s ulcer (SCC); (b) pyoderma gangrenosum; (c) vasculitic leg ulcers. Photographs reproduced courtesy of Medical Illustration, Norfolk and Norwich University Hospital.

TABLE 8.4

Key elements of a holistic needs assessment for lower limb conditions

• Calculate ABPI

• Assess skin, in particular noting signs of dryness, erythema or infection

• Check interdigital spaces for signs of fungal infection

• Note any general health problems

• Take a comprehesive medication history

• Assess level, type and duration of pain

• Check previous dressings

• Take vital signs, including temperature (especially if cellulitis is suspected)

• Evaluate impact on quality of life

• Discuss social situation, including who else is at home

• Evaluate mobility

• Determine need for other investigations (e.g. biopsy, wound swab)

with the skills needed to assess and manage lower limb conditions (Table 8.5).

Courses and training. There are various courses available for lower limb management. However, these often focus on specific aspects and do not cover all aspects of lower limb conditions. For example, a leg ulcer course may not cover lymphoedema, even though these conditions often overlap. Some of the courses count towards a postgraduate degree. Universities in Glasgow and Hertfordshire run chronic oedema and lymphoedema management courses. Many universities also run leg ulcer management courses locally, but content can vary. It is important to review these courses to ensure the content will cover your learning needs.

There are also many industry-developed e-learning modules. It is important to be aware that these are corporate with a focus on

Core knowledge domains and clinical skills for lower limb management

knowledge domains

Different conditions that present on the lower limb

A holistic approach to assessment, including ABPI where appropriate

Stages of wound healing

Types of dressings

Theory and types of compression bandaging and garments

Types of oedema

Red flags and when to seek urgent advice

Skin care and application of topical therapies, including emollients and topical steroids

Pain management

Psychological support

skills

HNA

ABPI

Compression bandaging

Compression garments (measuring and application)

Skin care (e.g. emollients, topical steroids)

Wound dressings (according to stage of wound healing)

skills

Skin biopsy

Diagnosis

Coordinating care in complex cases

treatments

Leading discussions in MDT meetings

promoting products; however, they can be a good starting point in developing the relevant knowledge and skills.

Who to talk to. It is helpful to talk to colleagues who have specialised in lower limb management. The BDNG can also provide direction with regard to educational opportunities and people in your local area who can be contacted for further advice.

Personal reflection

I never thought about being a nurse in dermatology when I qualified; however, I was inspired by a nurse during a lecture on a local leg ulcer course. I joined dermatology in 2009 and have been encouraged to specialise in lower limb conditions, including lymphoedema and lower limb cellulitis. I encourage other nurses not to rule out specialising in this field as there are so many avenues within dermatology that nurses can focus on. Providing patients with information on their condition can be both rewarding and satisfying, especially when the condition improves.

Key points – lower limb management

• Initial assessment of patients with common lower limb conditions is often undertaken by a dermatology nurse with advanced skills. Most patients are cared for in the community, but those with more complex conditions are referred to secondary care for MDT review.

• The importance of an HNA cannot be overemphasised as it ensures all aspects of care are considered and improves patient outcomes.

• Nurses of bands 5–8+ undertake a range of responsibilities in lower limb management, including wound care, ABPI, compression therapy and follow up –the higher the band the greater the level of independent decision-making.

• Dermatology nurses have a vital role helping patients understand the fundamentals of their condition and how to manage it. Being able to spend time educating patients and ensuring they follow an appropriate management pathway is immensely satisfying and rewarding.

• Numerous lower limb conditions are managed by dermatology nurses, including leg ulcers, cellulitis, red legs dermatoses and lymphoedema. Accurate assessment of these conditions is a critical skill that can prevent misdiagnosis and inappropriate treatment.

References and resources

1. 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-BDNGRCN-NURSING-WORKSTREAMA4-LANDSCAPE-002.pdf, last accessed 8 May 2021.

2. Wounds UK. Best Practice Statement – Addressing Complexities in the Management of Venous Leg Ulcers. Wounds UK, 2019. www.wounds-uk. com/resources/details/bestpractice-statement-addressingcomplexities-managementvenous-leg-ulcers, last accessed 8 May 2021.

3. Guest JF, Ayoub N, McIlwraith T et al. Health economic burden that wounds impose on the National Health Service in the UK. BMJ Open 2015;5:e009283.

4. National Institute for Health and Care Excellence. Leg Ulcer –Venous. National Institute for Health and Care Excellence, 2021. https://cks.nice.org.uk/ topics/leg-ulcer-venous, last accessed 8 May 2021.

5. Scottish Intercollegiate Guidelines Network. SIGN 120: Management of Chronic Venous Leg Ulcers. A National Guideline Scottish Intercollegiate Guidelines Network, 2010. www. sign.ac.uk/media/1058/sign120. pdf, last accessed 8 May 2021.

6. Legs Matter. Patients with Leg Ulcers, Wounds and Non-Healing Sores on the Leg. Legs Matter, 2022. https://legsmatter. org/help-information/forhealthcare-professionals/ ulcers-sores-and-knocks-onthe-leg-that-are-not-healing, last accessed 11 April 2022.

7. Ma nchester University NHS Foundation Trust. Leg Ulcer Pathway. Manchester University NHS Foundation Trust, 2016. www.nice.org.uk/guidance/ mtg42/resources/manchesteruniversity-nhs-foundationtrust-leg-ulcer-care-pathwaypdf-6718514511, last accessed 11 April 2022.

8. National Institute for Health and Care Excellence. UrgoStart for Treating Diabetic Foot Ulcers and Leg Ulcers Medical Technologies Guidance [MTG42]. National Institute for Health and Care Excellence, 2019. www.nice.org.uk/ guidance/mtg42

9. Cl inical Resource Efficiency Support Team. Guidelines on the Management of Cellulitis in Adults. Clinical Resource Efficiency Support Team (CREST), 2005. https:// legsmatter.org/wp-content/ uploads/2018/04/Cellulitisguidelines-CREST-05.pdf, last accessed 1 March 2021.

10. Phoenix G, Das S, Joshi M. Diagnosis and management of cellulitis. BMJ 2012;345:e4955.

11. Levell NJ, Wingfield CG, Garioch JJ. Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care. Br J Dermatol 2011;164:1326–8.

12. National Institute for Health and Care Excellence. NICE Impact Antimicrobial Resistance National Institute for Health and Care Excellence, 2018. www.nice.org.uk/media/ default/about/what-we-do/intopractice/measuring-uptake/ niceimpact-antimicrobialresistance.pdf, last accessed 1 March 2021.

13. E lwell R. Red Legs Pathway. British Lymphology Society, 2020. www.thebls.com/ public/uploads/documents/ document-84341639738140.pdf, last accessed 8 May 2021.

Further reading and resources

British Lymphology Society www.thebls.com

Legs Matter https://legsmatter.org

Lymphoedema Support Network www.lymphoedema.org

14. Br itish Lymphology Society. Lymph Facts: What is Lymphoedema? British Lymphology Society, 2020. www.thebls.com/public/ uploads/documents/ document-78261580330781.pdf, last accessed 8 May 2021.

15. Wounds UK. Best Practice Statement – Ankle Brachial Pressure Index (ABPI) in Practice. Wounds UK, 2019. www. wounds-uk.com/resources/ details/best-practice-statementankle-brachial-pressure-indexabpi-practice, last accessed 8 May 2021.

And a final word from our patients…

‘You are the first person ever to have asked me “how does this make me feel?” Thank you.’

‘I can go out without make-up on for the first time in 6 years. My life feels transformed.’

‘I was very glad to visit the dermatology department for my annual skin checks with the specialist nurses. It takes away the worry of not spotting another skin cancer.’

‘I hate needles of any form and was so nervous, but the dermatology nurses’ team could not have been kinder and got me through my procedure.’

‘My father has had so many skin cancers; we are grateful for the nurses’ attention and the time they have given to our concerns at each visit.’

‘Thank you very much for your kind, professional and knowledgeable approach to our consultation. I very much appreciated all your extra advice. I only wish I had met you much earlier. I was clearly in expert hands.’

‘Thank you so much for being so kind, caring and supportive – not to mention professional – in yesterday’s appointment. You made a big difference to how my husband and I were feeling regarding my condition, and that lifted us enormously.’

‘For the past 12 years, having regular appointments with the nurse-led service has made a huge difference to my wellbeing. I feel able to look out for danger signs, as the skills to do this have been carefully taught to me. Previously, I felt it was better to find out about recurrence later rather than sooner, but now I take a proactive stance.’

Useful resources

Professional organisations and academic institutions

British Association of Dermatologists (BAD) www.bad.org.uk

British Association of Skin Cancer Specialist Nurses (BASCSN) www.bascsn.com

British Dermatological Nursing Group (BDNG) www.bdng.org.uk

British Photodermatology Group (BPG) (special interest society of BAD) www.bpg.org.uk

DermNet NZ www.dermnetnz.org

Nursing and Midwifery Council www.nmc.org.uk

Primary Care Dermatology Society www.pcds.org.uk

Royal College of Nursing www.rcn.org.uk

St John’s Derm Academy www.stjohnsdermacademy.com

University of Hertfordshire www.herts.ac.uk

Charities and patient support groups

British Skin Foundation www.britishskinfoundation.org.uk

Cancer Research UK www.cancerresearchuk.org

Changing Faces www.changingfaces.org.uk

Macmillan Cancer Support www.macmillan.org.uk

National Eczema Society www.eczema.org

Psoriasis Association www.psoriasis-association.org.uk

Skin Support www.skinsupport.org.uk

e-Learning

BMJ Learning https://new-learning.bmj.com (access via Open Athens)

elearning for healthcare https://portal.e-lfh.org.uk/ (access via Open Athens)

National guidelines National Institute for Health and Care Excellence www.nice.org.uk

Scottish Intercollegiate Guidelines Network (SIGN) www.sign.ac.uk

Other resources

Levell N. Dermatology. GIRFT Programme National Specialty Report. NHS Publishing, 2021. https://cdn.bad. org.uk/uploads/2022/05/06132904/ DermatologyReport-Sept21o-FINAL15.9.21-3.pdf

Appendix 1: Patient assessment tool

Patient label Hospital

Date of referral

Date of assessment Assessment by

Patient history Family history

Description of lesion/rashSite

Body surface area (BSA) estimate

Occupation/hobbies Medications – prescribed & OTC (date started if recent)

Lifestyle

Psychosocial

Allergies

abbreviations list 5

ABPI (ankle brachial pressure index) 123, 124, 130, 132, 133 abuse of children 113–14 acute inflammatory lower leg conditions 126–9

Agenda for Change (AfC) banding 38–9, 57

AJCC (American Joint Committee on Cancer) 43 allergic contact dermatitis (ACD) 26, 28 American Joint Committee on Cancer (AJCC) 43 anaphylaxis 30 ankle brachial pressure index (ABPI) 123, 124, 130, 132, 133 assessment see patient assessment atopic eczema, paediatric 33, 110–12

BAD (British Association of Dermatologists) 80, 93 band levels career progression 11–14 independent prescribing 95 lower leg management 122–3, 124 paediatric dermatological nursing 107–8 patient assessment 21, 22, 25

band levels (contd) phototherapy 74–6, 82–3 skin cancer CNSs 38–9 systemic therapies monitoring 88, 89, 93

BDNG see British Dermatological Nursing Group (BDNG) benign skin cancer lesions 43 biological drugs 83, 93 British Association of Dermatologists (BAD) 80, 93

British Dermatological Nursing Group (BDNG) 10 competence levels 15, 16 courses/training 13, 33, 116 Dermatological Nursing journal 16 joining 16 patch testing best practice 30 phototherapy courses 82 role descriptors 12–14, 15, 57, 88, 108 skin cancer CNS descriptors 38–9

British Lymphology Society red leg pathway 128 bruising causes/ confusion 114 cancer screening 95 career progression 11–14 clinical skills 13 courses/training 32–4

career progression (contd) educational skills 14 leadership skills 13 lower leg management 130, 132, 133, 134 phototherapy 82–3 research skills 14

skin surgery 66, 69 systemic therapies monitoring 100–1

cellulitis 127–8, 129

chemotherapy for skin cancer 44, 46 children see paediatric dermatological nursing chronic inflammatory lower leg conditions 126–9 ciclosporin 89, 93 clinical nurse specialists (CNSs) 38–43, 47, 48–50

Clinical Resources Efficiency Support Team (CREST) 127 clinical skills career progression 13 investigations 25 lower leg management 124, 133 patch testing 28–9 patient assessment 22 phototherapy 75 skin surgery 66 systemic therapy 89 topical treatments 31 Clothier Report 107

CNSs (clinical nurse specialists) 38–43, 47, 48–50

communication skills 11, 17, 33, 40, 47–8 comorbidities 22, 94, 106

competence levels/ frameworks definition 15, 16 holistic assessment 20 lower leg management 124–5 phototherapy 77 Royal Pharmaceutical Society 95 skin surgery 60, 61–4 systemic therapies monitoring 90–2 see also core knowledge domains congenital dermal melanocytosis 114 core knowledge domains assessment 23 investigations 26 lower leg management 133 patch testing 28 phototherapy 77 skin cancer CNSs 41–8 skin surgery 56–7, 58 systemic therapies monitoring 93–100 topical treatments 30 COVID-19 pandemic 10, 93, 95

CREST (Clinical Resources Efficiency Support Team) 127 cryotherapy 44, 58 curettage 45, 63

dark-skin erythema 98 Dermatological Nursing journal 16 dermatology nurse skills 10–17 current state in 2022 10–11 key points 17

dermatology nurse skills (contd) patient care setting 11 requirements 11 specialisation within 11–14

Dermatology Quality of Life Index (DLQI) 21, 80, 94, 99 dermoscopy 21, 42, 43, 94, 99

direct observation of procedural skills (DOPS) 42, 60 disease severity tools 21, 95–8, 143–44 DLQI (Dermatology Quality of Life Index) 21, 80, 94, 99

Doppler assessment (aka ABPI) 123, 124, 130, 132, 133

EASI (Eczema Area and Severity) 79, 96, 98 eczema dark skin erythema 98 EASI 79, 96 paediatric 110–12 POEM 100 venous eczema 127, 129

educational skills 14, 47 electrocautery 45, 63 electrochemotherapy 46 erythema cellulitis/venous eczema distinction 129 dark-skinned individuals 98 EASI 96 MED testing 78, 79 PASI 96 patch testing 27 phototherapy 77–8 training 98

Fraser guidelines 112, 113 future developments 69–70, 83

Get It Right First Time (GIRFT) national report 10, 56 Gillick competency 112, 113

holistic needs assessment (HNA) 20 independent paediatric prescribing 109 lower leg management 130, 132 skin cancer patients 43, 47

immunotherapy 38, 44, 46 independent prescribing 95, 109–12

infections investigation 23–4, 25 inflammatory lower leg conditions 126–9

International Contact Dermatitis Research group criteria 27 investigations indications for 24 infections 23–4, 25 patch testing 26–30 patient assessment 23–30, 143–44 prick testing 24, 30 skin cancer 42–3 isotretinoin 93, 112

Kennedy Report (2010) 107

knowledge domains see core knowledge domains

leadership skills 12, 13, 38, 58, 82 leg ulcers 126, 127, 131 lifetime UV limits 76 literacy skills, patients 95 Lord Laming Report 114

lower leg management acute/chronic inflammatory conditions 126–9 assessment 130 career progression 130, 132, 133, 134 cellulitis 127–8, 129 common conditions 125–9 competencies 124–5 complex conditions 130, 131 core knowledge domains 133 key points 135 leg ulcers 126, 127, 131 lymphoedema 123, 126, 127, 128, 132 nursing role 122–4 patient care setting 124

patient education 125 personal reflection 134 red legs dermatoses 126, 127, 128, 129 scope of practice 122–3 training courses 132, 134 venous eczema 127, 129 lymphoedema 123, 126, 127, 128, 132

Macmillan sponsorship 38, 49, 139 malignancies see skin cancer

Marjolin’s ulcer 131 MED (minimal erythema dose) device 78, 79

medication independent prescribing 95, 109–12 isotretinoin 93, 112 topical steroids 33, 110–11, 126, 133 see also systemic therapies monitoring melanocytosis, congenital dermal 114 melanoma 38, 43, 44–6 mental health 10, 22, 84, 94 minimal erythema dose (MED) testing 78, 79

minor skin surgery procedures 57 Mongolian blue spots 114 monitoring erythema in phototherapy 77–8 phototherapy patient outcomes 79–80 skin surgery 68–9 see also systemic therapies monitoring multidisciplinary teams (MDTs)

complex lower leg conditions 130, 131 paediatric dermatological nursing 115 skin cancer care 39, 43, 44, 47, 50 systemic therapies monitoring 90–1

National Institute for Health and Care Excellence (NICE) 38, 91, 95, 96, 126 National Literacy Trust 95 never events in skin surgery 65 non-surgical skin cancer therapies 46

nursing roles

allergic contact dermatitis 28 descriptors (BDNGbased) 12–14, 15, 57, 88, 108 lower leg management 122–4 paediatric dermatological nursing 106–8

patch testing 29 patient assessment 20–4, 25, 28–9, 30 phototherapy 74–7

skin cancer CNSs 38–41 skin surgery 56, 57 systemic therapies monitoring 88–90 topical treatment use 30–2

objective structured clinical examinations (OSCE) 15, 66 online learning BPNG 13, 32, 33, 49, 66, 69, 82

DLQI 99

PASI/EASI 96 research 14

paediatric dermatological nursing 106–17 atopic eczema 110–12 child development 106–7 communicating with children 112–13 courses/training 106–7, 115–16 independent prescribing 109–12 key points 117 nursing role 106–8 patient care setting 108–9

paediatric dermatological nursing (contd) safeguarding children 113–14 scope of practice 107–8 teamwork 115 training 107

PASI (Psoriasis Area and Severity Index) 79, 80, 96–8 patch testing 26–30 patient assessment core knowledge domains 23, 26, 28, 30 holistic 20 investigations 23–30 lower leg management 130 nursing roles 20–4, 25, 28–9, 30 patch testing 26–30 prick testing 24, 30 process 20–1 proforma 143–44 skin cancer 42–3 systemic therapies monitoring 93 tool 143–44 validated tools 21 patient care setting 11 lower leg management 124 paediatric dermatological nursing 108–9 phototherapy 76–7 skin cancer 39 skin surgery 56 systemic therapies monitoring 88–90 patient education 94–5, 125 patient feedback 139 patient histories 42 patient safety 60, 65, 66 patient well-being 47, 78–9

Patient-Orientated Eczema Measure (POEM) 100 performance reviews 68, 71, 84 personal reflection 16, 50, 70, 134 phototherapy 74–84 applications 74 career progression 82–3 competencies 77 core knowledge domains 77 dose calculation 76 equipment/facilities 81–2 future developments 83 key points 84 nursing role 74–7 patient outcomes 79–80 patient well-being 78–9 service reviews 80–2 skin cancer 45 training courses 80–1 physical abuse of children 113–14

POEM (Patient-Orientated Eczema Measure) 100 practical skills/competencies 20–34 clinical band levels 22 holistic assessment 20 investigations 23–30 key points 34 systemic therapies monitoring 92 topical treatment use 30–2 training courses 32–4 validated assessment tools 21 see also nursing roles pregnancy 95, 112 prick testing 24, 30 proforma for patient assessment 143–44 protocols BDNG patch testing best practice 30

protocols (contd) definition 15 standard operating procedures 23 systemic therapies monitoring 90–1 Trust protocols for skin surgery 58–60

Psoriasis Area and Severity Index (PASI) 79, 96–8

pyoderma gangrenosum 131

quality of life

DLQI assessment tool 21, 80, 94, 99 opportunity to discuss 79 patient education 94–5, 125 patient well-being 47, 78–9 POEM assessment 100

radiotherapy 45 red legs dermatoses 126, 127, 128, 129 research skills 14 resources for learning 33, 49, 141 roles see nursing roles root cause analysis 65 Royal Pharmaceutical Society 95

safeguarding children 113–14 sample collection 23–4 scope of practice BDNG descriptors 12 definition 15 lower leg management 122–3

scope of practice (contd) paediatric dermatological nursing 107–8 phototherapy 74, 76 skin cancer CNSs 38–9 skin surgery 57–8, 59 systemic therapies monitoring 88, 89

self-harm, children 113 sexual activity, children 112, 113 skin cancer 38–51 career development 49–50 challenges/ opportunities 48–9 CNS core competencies 41–8 communication skills 47–8 incidence 38 key points 51 lesion assessment 42–3 nursing role 38–41 patient assessment 42–3 patient well-being 47 personal reflection 50 therapeutic interventions 44–6 skin surgery 56–71 advanced procedures 57 BDNG role descriptors 57 career progression 69 competence levels/ frameworks 60, 61–4 core knowledge domains 58 facilities standards 66–7 future developments 69–70 key points 71

skin surgery (contd) minor/advanced procedures 57 monitoring 68–9 never events 65 nurses’ needs 69 patient safety 60, 65, 66 performance reviews 68 personal reflection 70 root cause analysis 65 service needs 68 standards 66–7 training courses 66 Trust protocols 58–60 specialisation 11–14 see also career progression standard operating procedures (SOPs) 23 standards 66–7, 80 steroids, topical 33, 110–11, 126, 133 surgery see skin surgery systemic therapies monitoring 88–101 career progression 100–1 competence levels/ frameworks 90–2 core knowledge domains 93–100 Dermatology Quality of Life Index 99, 100 disease severity tools 95–8 key points 101 multidisciplinary teams (MDTs) 90–1 nursing role 88–90 patient assessment/ screening 93 patient education 94–5 POEM 100 practical skills/ competencies 92 protocols 90–1 scope of practice 88, 89 theoretical competencies 92

talking to other colleagues

15–16, 101, 134 targeted therapies for skin cancer 45 teamwork see multidisciplinary teams (MDTs) terminology/definitions

5, 15, 65, 113

theoretical competencies 92 tools for validated assessment 21, 95–8, 143–44

topical treatments nursing roles 30–2

paediatric steroids 33, 110–11, 126, 133 skin cancer 44 training courses 32, 33, 34 disease severity tools 98 lower leg management 132, 134 paediatric dermatological nursing 107, 115–16 phototherapy 80–1 skin surgery 66 see also career progression

Trust protocols for skin surgery 58–60 tumour-node-metastasis (TNM) classification 43 type 1 (immediate) reactions 30 type 4 (delayed) reactions 26 ultraviolet light 74, 76 vaccination 94–5 validated assessment tools 21, 95–8, 143–44

vasculitic leg ulcers 131 venous eczema 127, 129

work-based learning