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I’m sure we’ve all come across this during a HMR. You ask the patient
or carer to show you their medicines and they bring out a few tablets.
Probe deeper and you end up with all manner of OTCs, eye drops, nasal
sprays etc, not listed on any medication history. Possibly the biggest
volume of unused and often expired medicines that I return to the yellow
bin after an HMR, are topical corticosteroids (TCS).
Interventions in dermatology can
really improve quality of life. Recall that
many patients who have HMRs do not
regularly visit the pharmacy themselves,
and when they do they have a lot to deal
with in one transaction. So an HMR can
be a great opportunity to view and deal
with aged skin.
Right about now the westerly winds
blow dry across our barren country,
bringing with them an annual cycle of
dry skin, itch and concern. Aged skin
is particularly susceptible at this
time. Not only does the skin dry out
intrinsically, extrinsic factors such as
sunlight exposure, smoking, and the
environment have a role. Add to this any
of: decreased mobility, atherosclerosis,
diabetes, heart failure, thyroid disease,
anti-androgen medications, diuretic
therapy, human immunodeficiency
virus, malignancies and cutaneous
manifestations of inflammatory
diseases, and it is easy to see why the
paper thin skin covering the shins of our
patients is xerotic (Xerosis is itchy dry
scaly skin with fissures or fine cracks).
Once the skin is cracked it becomes
more sensitive to allergens and further
itching, leading to a cycle of itch-
scratch-itch. Occasionally the cracks will
weep, and left untreated, infection and
ulceration is unfortunately common.
During an HMR we can give advice
such as: improving circulation, using
emollients, humidifying the dry air,
avoiding strong soaps and treating
obvious infection early. TCS have an
important role in reducing inflammatory
response in dry older skin.
For years GPs and pharmacists were
taught (by dermatologists) to be careful
with TCS. My 2002 AMH advised to
use TCS sparingly even though the
‘finger-tip’ unit was identified in 1991.
It seems we were too cautious. As Debbie
Rigby recently highlighted, TCS should
be applied liberally not sparingly.2
Now, dermatologists and particularly
paediatric dermatologists, commonly
voice their frustration that pharmacists
are too conservative and provide
patients with outdated risk messages.
Our research team is about to publish a
study outlining Australian patients’ and
caregivers’ experiences with GPs and
community pharmacists in relation to
advice about using TCS.
Suffice to say,
both GPs and community pharmacists
require re-alignment in this practice area.
Readers are of course referred to
Therapeutic Guidelines (TG) for
current information about using TCS.
The recommendations are that TCS
should be used early, liberally, once daily
to all areas of inflammation including
broken skin, and even up to the borders
of wounds. They should be used for
Topical corticosteroids on
old dry skin
BY DR STEPHEN CARTER MPS
at least 1–2 weeks and stopped only
when the skin is looking not inflamed
and re-started again if needed. If, for
example you are treating two mildly
inflamed legs, triamcinolone 0.02%
ointment (rather than cream, if possible)
could be recommended and a 2-week
course could require between 100 g
and 200 g. For longer treatment periods,
intermittent therapy such as every other
day, weekend-only application or a
resting period of 1–2 weeks between
cycles may be an option.6 When making
recommendations for under-treated
patients, accredited pharmacists
could familiarise themselves with the
comparative tables in TG and AMH.
This could help provide prescribers
with options, in order to reduce the
psychological reactance that prescribers
feel when receiving recommendations
However, caution is still worthwhile.
A 2013 Australian Prescriber article
reminds us that: ‘Atrophy of the skin is
one of the most common cutaneous
Dr Stephen Carter is a lecturer in the Faculty of
Pharmacy, Sydney University, and a community
pharmacy owner and has been accredited to perform
medication management reviews since 1997. He is
currently Vice-President of PSA NSW Branch.
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