20 September 2001
Ms A Field
Head of Policy, Executive Support
Department of Health
MCA
Market Towers
1 Nine Elms Lane
London SW8 5NQ
Extended Prescribing of Prescription Only Medicines by Independent Nurse
Prescribers
Response from the British Association of Dermatologists.
Dear Ms Field
Thank you for the opportunity to respond to this document. As stated in our original
response to the draft proposals on extending nurse prescribing, we are strongly in favour
of increasing the prescribing role of nurses within an agreed local framework for the
provision of dermatological services. Experienced dermatologically trained nurses play a
major role in the management of patients with skin disorders and it is right that they
should be able to prescribe treatments for those with diagnosed skin disorders. In
addition to the specific points that you have requested a response to, we feel that the
following important points have not been addressed in the plans for extending nurse
prescribing:
1. Misuse of term 'Minor Ailments'
You have already received strong representation from patient support groups representing
those with skin diseases, dermatology nurses and dermatologists pointing out the serious
error in considering dermatological diseases as 'minor ailments'.
None of the skin disorders you consider appropriate for nurse prescribing is a minor
ailment. All have a major impact on quality of life and several have complications that
carry significant morbidity and even mortality. That cellulitis should be considered a
minor ailment is negligent. It is a serious, potentially life-threatening infection and
inadequate treatment can have serious deleterious consequences.
Almost all the conditions in this section would be better described as 'common chronic
disorders'. This would avoid terminology that is both inaccurate and demeaning to the
many individuals who suffer from disorders already suffering the stigma of being 'nonacute' and therefore less deserving of resources.
2. Diagnosis of diseases to be treated by nurse prescribers
Again in this document, there is no reference as to who will make the diagnosis of the
disease to be treated by a nurse with rights to prescribe. However, the implication is that
nurses will be making the diagnosis and treating the patient since many of the "Caution"
statements under specific sections state "if…..medical assessment is necessary". The
concept of nurse diagnosis has not been openly and explicitly stated in any of the
documents on Nurse Prescribing sent out for consultation. These are two very different
matters and the skills and length of training required to make a diagnosis are quite
different from those to prescribe a treatment.
Experienced specialist nurses may develop diagnostic expertise but there are many
pitfalls in diagnosis requiring in depth medical knowledge. For example, in dermatology,
differentiating between cellulitis, deep vein thrombosis and acute contact dermatitis can
be extremely difficult. Determining whether atopic eczema is infected by herpes virus or
by a bacterial infection requires medical knowledge as well as experience. These events
are common and the potential for serious complications if they are incorrectly diagnosed
and treated is real.
Other common dermatological problems such as scabies, skin fungal infections and
urticaria can present very difficult diagnostic decisions even for experienced
dermatologists. There is evidence of a very significant waste of resources where these
conditions are misdiagnosed, not to mention the inconvenience and risk to those wrongly
diagnosed.
The medico-legal consequences of making inaccurate diagnoses are clearly different and
separate from any consequences arising from errors or problems with nurse prescribing.
We remain strongly of the opinion that the diagnosis of a skin disorder should be clearly
established by a doctor before a nurse takes on the prescribing responsibilities for an
individual patient.
3. Treating Psoriasis
There is no mention of nurses prescribing for psoriasis, one of the commonest chronic
skin disorders and one in which nurses could have a key role for helping to find the most
suitable treatments. The list of topical therapies does not include common anti-psoriatic
therapies such as topical vitamin D creams, mild topical tars or short contact dithranol
preparations (see British National Formulary for details of available agents). All of these
are far safer than the super potent topical steroids that have been included on the lists.
This is a very important omission and we would strongly recommend that treatments for
psoriasis be included.
4. The Inclusion of Super-Potent Topical Steroids
The list of topical drugs that may be prescribed by nurses includes the super-potent
topical corticosteroids, clobetasol propionate and diflucortolone valerate. These have
potency roughly equivalent to 1000 times that of hydrocortisone and 10 times that of the
common potent topical corticosteroids. Side effects from the misuse of super-potent
topical steroids include permanent skin thinning and stretch marks. Used in excess, they
can cause systemic immunosuppression. They should not be used in children except very
rarely for specific well-defined skin diseases (not those in this document).
The use of super-potent topical steroids in undiagnosed skin disorders can obliterate
clinical and histopathological changes necessary to confirm the nature of the problem.
Inappropriate use on unrecognised fungal infections hides the normal features of the
infection and allows it to spread.
We would urge that the prescription of super-potent topical steroids be limited to doctors.
5. The Inclusion of Substances which are common causes of contact allergy
Contact allergic reactions to the constituents of medicaments are a common cause of
allergic contact dermatitis. Certain agents are well known to be common sensitisers and
it is important to restrict their use to very specific situations.
These common sensitisers include the topical antibiotic NEOMYCIN and the related
antibiotics, Gentamicin, Bacitracin and Polymixin. This is particularly important when
treating patients with leg ulcers who commonly develop multiple contact allergies.
Allowing these agents to be more widely used than they are now will increase the number
of patients developing allergic reactions to them. There is no indication for their use in
treating any skin disorder.
6. Antibiotic Resistance
There are great concerns about antibiotic resistant strains of bacteria, particularly MRSA.
Microbiologists generally consider that Mupirocin should be strictly limited in its use to
try and maintain it as one of the few antibiotics still useful against MRSA. This is
discussed further under the section on Impetigo (3.7.11)
To answer the specific points that you have invited comments on:

The Definition of Nurses able to Prescribe
A 3-month training programme is inadequate to enable the nurse to prescribe all the
medications on the extended list. It is not made clear whether they will be expected to
become competent in all areas of prescribing or just those relevant to one group of
medical disorders. We do not think that adequate training in the correct use of topical
preparations for skin diseases can be learnt in such a short period. It is not the same as
looking up the dose in a book and writing a script. It is very much an experience-based
process. Guidelines do not give an indication of how an individuals skin will respond to
particular preparations.
Training in the use of topical medicaments MUST be given by nurses or doctors who are
dermatologically qualified. The 'prescribing mentor' for any nurse who will prescribe
treatments for skin disease must have dermatological training and experience.
As discussed above, if nurses are to diagnose as well as treat then a three month
course is completely inadequate.

Proposed Medications for Dermatological Disorders to be Prescribed by Nurses
6.7.1 Acne
Management: It is stated that systemic Roaccutane "should" only be prescribed by a
dermatologist. This drug MAY only be prescribed by a dermatologist legally.
Some drugs can cause acne-type rashes.
Cautions: Any acne not responding to treatment requires further medical assessment.
POM's for Inclusion: The topical agent benzoyl peroxide is not included on the list
despite the fact that there is evidence for its effectiveness and it is cheaper than all the
other suggested topical agents listed. It is also now suggested that benzoyl peroxide be
used in combination with topical or systemic antibiotics in treating acne as there is
evidence that it helps to lessen the risk of antibiotic resistance. We realise that benzoyl
peroxide can also be bought over the counter but it is often prescribed.
6.7.2 Boil/Carbuncle
Cautions: Chronic staphylococcal carriage in the nose and scalp should be identified and
treated.
Hidradenitis suppurativa, characterised by comedones, scars and recurrent boils in
flexural sites must be diagnosed and properly managed.
6.7.3 Candidiasis- skin
To suggest that most intertriginous and toe-web infections are due to candida (a yeast
infection) will miss a significant number of cases caused by tinea (a fungal infection).
Toe-web fungal infections are commonly linked with fungal infection of the skin of the
feet and/or the nails. These require systemic treatment and the diagnosis should be
established with appropriate cultures of skin and nail. Not all topical anti-candidal agents
(e.g. nystatin) are active against tinea.
The section in this document seems confused in only mentioning candida infection but
then defining treatment as 'anti-fungal'.
6.7.4 Cellulitis
Cellulitis is a medical emergency. Infection can progress very rapidly. Inadequate
management can lead to tissue loss, septicaemia and long term complications such as
lymphoedema. High dose oral antibiotics may be adequate if the infection is caught early
but intravenous antibiotics are essential for established serious cellulitis.
The diagnosis of the portal of entry for infection (otitis externa, tinea pedis etc.) must be
established and treated.
The long-term management of residual lymphoedema is imperative to prevent recurrent
attacks of cellulitis.
Considering cellulitis as a 'minor ailment' is completely unacceptable. It should be
considered in the same way as acute pneumonia, peritonitis or any other serious bacterial
infection.
6.7.5 Chronic skin ulcer
Management: Pressure ulcers and leg ulcers must be managed by nurses with training and
expertise in these specific disorders.
The mention of oral pentoxifylline for which there is little data and which is not licensed
for use in these disorders seems unnecessary.
Cautions: All atypical leg ulcers should be properly diagnosed. Ulcerating skin cancers,
pyoderma gangrenosum and other vasculitic disorders will be overlooked if the sole
assessment of an ulcer is by ankle-brachial pressure index.
6.7.6 Dermatitis - atopic
Definition: Atopic eczema currently affects 15-20% of children.
Management: The choice of topical steroid depends on age of patient, disease severity,
body site involved and area of skin affected. Considerable experience is necessary to
prescribe safely and effectively, particularly for children.
Secondary infection is common. Staphylococcus aureus, haemolytic streptococcus and
herpes simplex virus all need to be identified by culture and managed appropriately.
Cautions: The use of super potent topical steroids and has significant risks as detailed in
4 above.
A doctor should initiate treatment with super-potent topical steroids. Repeat
prescriptions and total usage should be carefully monitored.
There is little evidence that steroid/antibiotic combinations are more effective than
steroids alone and their use risks inducing antibiotic resistance or contact allergic
reactions.
3.7.7 Dermatitis - contact
Cautions: The same potential risks for the use of topical steroids exist as for atopic
eczema.
3.7.9 Dermatophytosis of skin (ringworm)
Cautions. Diagnosis of fungal infections must always be confirmed with appropriate
laboratory cultures. This is particularly true for scalp ringworm where the accuracy of
diagnosis, even by experts, is poor. There is a Public Health Laboratory Service
document to support this. Scalp ringworm will virtually always require systemic therapy
and is therefore not appropriate for nurse prescribing under these guidelines.
3.7.11 Impetigo
As described, neomycin is a common skin allergen. There is no place for its topical use.
Cicatrin cream and powder and Neomycin and Gramcidin ointment should not be
included.
Mupirocin Cream and Ointment should not be used. The majority of
Microbiologists now recommend that mupirocin is reserved for strictly controlled
use in patients with MRSA (multiple drug resistant staphylococcus aureus)
infections. Allowing it to be widely prescribed for infections such as impetigo risks
loosing one of the few available drugs to treat MRSA.
Mupirocin should be deleted from the list of drugs that can be prescribed by nurses.
3.7.12 Nappy Rash
Diagnosis: Not all rashes in the napkin area of infants are nappy rash. Atopic and
seborrhoeic eczema and psoriasis can cause diagnostic difficulties.
Management: Secondary bacterial infection may be with streptococcus as well as
staphylococcus. Swabs should be taken and correct antibiotics prescribed.
3.7.16 Warts and Verrucas
No mention is made of molluscum contagiosum, (a very common viral skin infection in
children causing small inflammatory lesions anywhere on the body) or of how to
approach the problem of viral warts on the genital area in children.
3.9.2 Candidiasis - vulvovaginal
Cautions: Candidiasis is not the only cause of itching in the vulvavaginal area. Eczema
(atopic, contact or seborrhoeic), psoriasis and other well defined skin disorders are
common in this area. All patients must be examined in appropriate conditions with a
good lamp and swabs should be taken to confirm the diagnosis of candida infection.

Oral and Topical Antibiotic Prescribing
The issues around the use of topical antibiotics and bacterial resistance in acne have been
discussed in the points above.
Conclusions
Nurses with appropriate skills, training and experience should be able to prescribe a wide
range of drugs for diagnosed diseases.
The response of the British Association of Dermatologists outlines some problems in
prescribing for the skin disorders specified in this document.
Most importantly, we wish to see the issue of diagnosis being taken seriously and
specifically addressed. Who makes a diagnosis and who takes responsibility if it is
incorrect? Throughout this document, the implication is that nurses will see and treat
patients with certain conditions first, passing them on for 'medical assessment' if
problems persist or arise. However, it is never clearly stated that responsibility for the
diagnosis in an individual patient rests with the prescribing nurse.
Misdiagnosis can result in inconvenience, disillusionment and harm to individual patients
and an enormous waste of limited resources. The whole debate about the experience,
qualifications and appropriate training that will enable nurses to become diagnosticians
have not been addressed in any of the documents relating to nurse prescribing.
The whole concept of clinical governance is about the accountability of institutions and
individuals for the safety of their practice. Ignoring the issue of accountability in making
a diagnosis before instituting and prescribing a treatment is not acceptable.
We hope that these comments will not be seen as a negative, elitist or 'Luddite' reaction,
or an attempt to limit the expanding roles of nurses. As a specialty, we work very closely
with dermatology nurses and have fully supported the innovative roles they continue to
develop. They have particular skills in the practical aspects of using topical therapies that
are invaluable to patients. We know that access to good dermatological care for those
suffering from skin disease is very limited and we wish to make it easier for patients to
find the help that they need. What we wish to avoid are nurses, however well motivated,
without adequate skills in the diagnosis and management of skin diseases prescribing
incorrectly, and the ensuing deleterious impact on those who most need help.
We would very much appreciate a response to these comments.
Yours sincerely
Dr Katharine L Dalziel
Honorary Secretary