Skin Problems in Primary Care

Written by Dr Brian Higgins Managing Partner, Galway Primary Care Medical Director, Galway Skin Clinic

Identifying, diagnosing and treating dermatological conditions can be difficult, not only because of the vast range of disease but also the complication of an often confusing range of products and prescription medication that patients may use prior to seeking help.

I hope that by sharing my approach to managing dermatological issues it may be of help to you in your own clinical settings for your patients.

Where to begin

“Will you look at this?” The line which we pray is followed by a sleeve rolling up and not pants sliding down, is generally how it starts. The temptation is always there to attempt a diagnosis by inspection alone but that often misses the most crucial diagnostic information – the history.

Every rash has a story – When did it start? Is this the first time you have had this rash? How does it feel? Does it itch, burn, sting, come and go? Is it spreading? Do you have it anywhere else that you might not be as comfortable showing me? Does anything make it worse? Has anything changed in your work or home life in the weeks before the rash appeared? Have you been putting anything on it and if so what has that done to it?

All of these questions build a picture, a picture as important as the one you see with your eyes.

Common things are common

I worry about cutaneous lupus and T-cell lymphomas, but thankfully these are rare. Whereas acne, eczema, psoriasis, impetigo, seborrheic dermatitis, shingles, chickenpox, herpes, irritant dermatitis and rosacea are all extremely common.

Familiarizing yourself with the above rashes, getting confident in their diagnosis and being comfortable with advising some high quality products for home use, or alternatively knowing when a medical review is required, will be a great support to your patients.

Diseases behaving badly

As a GP, I reserve consultant referral for what I call Diseases Behaving Badly. As a GP I should be able to diagnose and treat the vast majority of cases I see. When the disease is not responding as it should to empiric treatment, I know that this is an unusual case – either more severe than normal, or perhaps one illness masquerading as another, and specialist input is required.

How does this apply in pharmacy? Well, think of the common illnesses you are going to see – eczema, acne and seborrheic dermatitis. In milder cases, using over the counter, pharmacy grade skin care that is appropriate for the condition and skin type should make a considerable improvement to the condition. If it doesn’t, that’s a disease behaving badly and a referral to the patients’ GP for prescription treatment of further investigation is warranted.

What products should I be advising

In my journey through dermatology, a field that has always fascinated me due to my personal battles with eczema, I reached a significant milestone in 2022 by establishing the Galway Skin Clinic. My goal was to introduce advanced medical skincare solutions to the community, driven by a lifelong passion and two decades of medical experience.

However, the vast and seemingly boundless array of skincare products on the market was both astonishing and overwhelming. The challenge wasn’t just about choosing brands; it extended to navigating the extensive product lines each offered. This complexity made it difficult to decide where to begin.

The strategy I adopted focused on three key aspects:

Price Spectrum: I considered products across three price categories—budget-friendly, mid-range, and high-end—to cater to diverse client needs and preferences.

Value in Ingredients: It’s crucial to ensure that the product’s price reflects its ingredients’ quality and efficacy, rather than the cost of marketing. Often, products with anti-aging properties command a higher price, but younger clients can achieve remarkable results with more affordable options.

Tailored Selection: I prioritize products that address the most common skin conditions we encounter, such as eczema and acne. Understanding these conditions deeply allows for a more informed selection of products. Collaborating with company representatives has been invaluable; they serve as excellent resources, offering detailed product knowledge and recommendations.

To provide a comprehensive skincare range, I’ve chosen to stock esteemed brands like Avene, Relife, Mesoestetic, Skinceuticals, Revision, and Skin Better Science, each selected for their proven results and alignment with our clinic’s ethos and our patients’ needs.

Prescription treatments

In practice, the most common prescriptions you’re likely to encounter are for eczema and acne. For eczema, a frequent misunderstanding among patients is the hesitancy to use adequate amounts of steroids. Contrary to the often-misleading advice to use steroids ‘sparingly’, they should, in fact, be applied generously as needed. This confusion can lead patients to underuse, necessitating prolonged treatment durations. The recommended dosage is a fingertip unit, meaning a line of cream from the distal crease to the fingertip should suffice to cover an area the size of two palms.

Regarding emollients, I observe two prevalent errors. Firstly, some patients mistakenly use their steroid creams as emollients, which can lead to complications like skin thinning. Secondly, applying the steroid after the emollient can be ineffective, as the emollient may act as a barrier, significantly reducing the steroid’s efficacy. I advise patients to apply their prescribed steroid first, followed by a brief interval—perhaps having breakfast or brushing their teeth—before applying the emollient.

Acne treatments can vary significantly, ranging from topical retinols, antibiotics, and acids to oral antibiotics, the oral contraceptive pill, and isotretinoin. These patients require extensive education and support. It’s crucial to manage expectations by highlighting that for moderate to severe cases, noticeable results may take up to three months. Patients should be encouraged not to abandon their regimen prematurely and to return for a review if there’s no improvement after three months, allowing for treatment adjustments or escalation as necessary.

More than skin deep

It’s imperative to acknowledge the profound psychological toll dermatological issues can impose on individuals. The intricate link between our appearance and selfidentity means that even seemingly minor skin conditions can lead to substantial emotional distress. Notably, conditions like acne are associated with an elevated risk of suicide, highlighting the critical need for comprehensive patient care. In our practice, we prioritise not only the physical treatment of skin ailments but also the mental well-being of our patients.

Each consultation is an opportunity to assess their psychological state, offering support and ensuring they know help is always within reach.