Intervention

A key element of the care planning process is to formulate decisions regarding the appropriateness of treatment. As well as working within multi-professional teams and contributing to such decisions, nurses will be making some treatment choices in a growing number of countries with the appropriate nurse prescribing qualification or professional preparation. Each section, within the specific clinical area or condition discussed, will address issues of treatment, but as an overview, a summary is given here in Table 3.8 categorising the main treatment regimens commonly used within the dermatological field.

Table 3.8 Categories of common dermatological treatments.   1. Pharmacological a. Topicals: emollient (focus Emollients), tars, dithranol, topical immune-modulators, steroids, vitamin D analogues, retinoids, keratolytic agents, antibiotics, antifungal and antiviral drugs. b. Systemic: immunosuppressive agents/ biological therapies, antibiotics and antifungals, retinoids, steroids, antiviral agents and antihistamines. 2. Phototherapy: UV, including narrow band (A and B), photodynamic therapy 3. Surgical, cryotherapy, laser: Skin biopsy (punch, shave, incisional biopsy and excision), curettage and cautery, skin grafting, Mohs microscopically controlled excision and cryotherapy (liquid nitrogen). Laser therapy: quasi-continuous wave and pulsed. 4. Psychological and educational: (details given in Helping patients make the most of their treatment) 5. Iontophoresis (for hyperhidrosis, excessive sweating) 6. Bandages and dressings

Treatment protocols and guidelines tend to stage therapy in accordance with the severity of disease and the patients response over time; assessment of the patient’s response at each stage is required. For example, in the case of psoriasis, patients are likely to commence with topical therapy and be supported in self-management wherever possible. This may proceed to phototherapy or a combination of light therapy. For those with more severe disease, they may progress to systemic/oral therapy and thereafter possibly onto biological therapy. Such progression would require assessment not only in changes in disease severity but also perhaps in disease-related quality of life and the patent’s self-management ability, in relation to topical therapy.

Phototherapy assessment requires a systematic assessment of the patient’s skin type and previous history of UV exposure and response to inform the assessment of a suitable dose regimen. The response to phototherapy needs to be assessed, both in terms of the disease severity and adverse effects, such as erythema and dryness of skin. The individual’s skin response to UVB depends on their skin phototype, prior exposure to sunlight or other source of UV and the presence of photosensitivity. Typically for UVB therapy, the minimal erythema dose (MED) is measured; these vary widely within each skin type. A template is applied to a non-exposed area, such as the volar surface of the arm; test sites are outlined with a skin marker so that they can be identified. The response is measured 24 h later. The MED is the lowest dose that produces pink erythema with distinct borders.

The use of systemic therapy requires a complex monitoring regimen not only to determine suitability for treatment (to meet guideline requirements and patient protection, e.g. pregnancy) to monitor therapeutic effect, but also to assess for adverse effects in order to manage risk from cytotoxic agents. An increasing number of nurses are involved in monitoring patients on such therapy. For example, methotrexate use requires liver and renal monitoring, pulmonary review and a full blood count (Wakelin, 2002). Biologic monitoring is complex. A growing number of nurses are playing a key role in the monitoring of both treatments, shorter- and longer-term response, especially to pick up any adverse effects. Short-term monitoring will involve monitoring for infusion reactions with TNF inhibitors (e.g. Infliximab) such as hypotension, dyspnoea and urticaria (anaphylaxis). Adverse effects include headaches, gastrointestinal upsets and chills. Longer-term monitoring will involve the use of PASI and a review of risk such as infection (hepatitis B reactivation, tuberculosis, hepatotoxicity and malignancy). For further details see Psoriasis.