“I actually monitor the infliximab cohort and also, I do monitoring for patients who are on systemic medications – DMARDs such as methotrexate and azathioprine”, she explains

“Having a skin condition is something that can take over people’s lives”, says Ms Bryant. “It just impacts people’s confidence and so it’s just so, so important and shouldn’t ever be underestimated …….. and we should do everything we can to support them [to] get the best out of their medicines so that they can achieve the very best skin that they can”.

Pharmacists can help patients to get the most out their medicines by helping them to work out regimens that achieve the best therapeutic effect with least impact on day-to-day life.

Feedback from a satisfied patient illustrates the impact that good pharmaceutical care can have on dermatological disease. After Ms Bryant had worked with him to optimise his treatment he said, “My skin is absolutely fantastic, it’s been the best it’s been for years! I can go out now and wear a pair of shorts and without feeling self-conscious”.

Psoriasis treatment can be thought of like “tools in a toolbox” says Ms Bryant.  Whilst Systemic treatment takes much of the load, topical treatments be adjusted to meet the patient’s needs. Educating patients to manage their own skin is also an important part of her work. “It’s upskilling and educating the patient to know that they can manage their own skin condition”, she says.

After managing the switch to biosimilar infliximab at Liverpool University Hospitals, Ms Bryant continued to monitor the infliximab cohort of patients. Now, she routinely undertakes therapeutic monitoring – infliximab trough levels and anti-infliximab antibody levels – for this group of patients. As part of the assessment in the clinic Ms Bryant will also examine the patient’s skin and estimate the psoriasis area and severity index (PASI) score and the dermatology life quality index (DLQI) score. A PASI score is important when systemic treatments are started (and is required by some NICE guidance) and is also important for monitoring the response to treatment.

Pharmacists need to have patients’ skin in mind regardless of what initially brought them into hospital. She suggests that pharmacists should look out for medications associated with skin conditions as a matter of routine conditions even though that might not be the reason that the patient has been brought into hospital. “If we ignore the patient’s skin at that point …. then the skin might flare up and become a problem”, she says.

The establishment of a specialist dermatology pharmacist network and the collaborative work with the British Association of Dermatologists underlines the important contribution that pharmacists can make to this specialty.

Kläre Bryant is an advanced clinical pharmacist in dermatology at Liverpool University Hospitals NHS foundation trust. She has an outpatient clinic at Broadgreen Hospital for patients receiving biologic therapies and another clinic at Aintree hospital for patients receiving systemic disease modifying anti-rheumatic drugs (DMARDs)

Read and watch the full series on our website or on YouTube.

Pharmacists need to have patients’ skin in mind regardless of what initially brought them into hospital.

Ms Bryant says: “We all put moisturiser on our skin some part of everyday – hand cream, face cream, anything – so your patients are going to need to do that as well. [We need] to recognize how important controlling the patient’s skin is and [take steps to] allow the patient to be comfortable in their skin despite whatever else is going on for them in hospital”. She suggests that pharmacists should look out for medications associated with skin conditions even though that might not be the reason that the patient has been brought into hospital. “We need to ensure that the patient’s skin is catered for …… and always look to see if the patient has any dermatology creams and things which will need prescribing. Get them prescribed – if we ignore the patient’s skin at that point and focus on the patient’s primary concern then the skin might flare up and become a problem. So, it’s really important to always bear this in mind”, she says.

Pharmacists should consider specialising in dermatology because it is “fantastically interesting”, says Ms Bryant.

“It’s not just that tube of cream that you might see sitting there on the shelf – there’s so, so much more to dermatology than what you might think on the face of it. There are the creams and the topicals that the patient will use, there’s the tablets that the patient might take and there’s biologic medicines – and there’s a whole load of immunology with that as well. There’s thousands of skin conditions and it’s just really interesting. Lots of unlicensed or off-label medication is used within dermatology, as well. ….. There’s so much to do in dermatology and it is really interesting once you scratch the surface of it”, she says.

Dermatology pharmacy interest group

An interest group for specialist dermatology pharmacist has now been formed.  Kläre recalls, “When I first started as a dermatology pharmacist I wasn’t aware of any [dermatology pharmacy] groups that I could get involved in ……….. so I thought I was the only dermatology pharmacist for a few years!” Later she came into contact with Arlene Maguire at Guy’s and St Thomas’ hospital in London who had already set up a dermatology specialist dermatology pharmacist group on the NHS network.

Ms Bryant is a founder member of a national specialist dermatology pharmacist network group. Some meetings have already been held to provide education in dermatology for pharmacists. A face-to-face meeting was held in 2021. “That was a great meeting to get that group of dermatology pharmacists together and get to know each other and not feel so sort of on your own really”, she says.

More recently, the British Association of Dermatologists has started to set up some resources for dermatology pharmacists. Ms Bryant is involved in the pharmacists’ work stream as part of this project. Educational resources are being developed for primary care pharmacists to upskill them in dermatology. There will also be resources for secondary care pharmacists such as examples of job descriptions and business cases. All these developments should help pharmacists to develop their roles in the dermatology team.

Ms Bryant welcomes this initiative and says, “It’s absolutely fantastic to know that pharmacists are on the BAD’s radar”.

Kläre Bryant is an advanced clinical pharmacist in dermatology at Liverpool University Hospitals NHS foundation trust. She has an outpatient clinic at Broadgreen Hospital for patients receiving biologic therapies and another clinic at Aintree hospital for patients receiving systemic disease modifying anti-rheumatic drugs (DMARDs)

Read and watch the full series on our website or on YouTube.

Over time her role in the clinics has developed and become more specialised. After managing the switch to the biosimilar drug, she continued to monitor the infliximab cohort of patients. She routinely undertakes therapeutic monitoring – infliximab trough levels and anti-infliximab antibody levels – for this group of patients. She also works in the dermatology inpatient ward and the day-case area where patients receive infliximab infusions and so she is involved in the whole patient journey.

Monitoring of patients receiving systemic therapies follows the schemes set out by the British Association of Dermatologists. Local templates have been developed that incorporate all the BAD guidance and checklists are used to ensure that all the relevant questions are asked and tests ordered. Routine blood monitoring includes a full blood count and liver function tests. Patients receiving methotrexate may also need PNP (type III procollagen peptide) and FibroScan monitoring at times, says Ms Bryant. In addition, checks are made for signs of infection, that patients are up-to-date with vaccinations and that they are tolerating their treatment. Clinic visits also provide an opportunity to have a discussion with the patient about treatments and make adjustments if necessary.

As part of the assessment in the clinic Ms Bryant will examine the patient’s skin, estimate the psoriasis area and severity index (PASI) score and the dermatology life quality index (DLQI) score. A PASI score is important when systemic treatments are started (and is required by some NICE guidance) and is also important for monitoring the response to treatment, she explains.

During the coronavirus pandemic much of the clinic work was switched to telephone consultations. Ms Bryant explains: “We were able to do telephone consultations especially for follow-up patients for monitoring. So, I continued with my clinics as normal – almost normal – but doing it on the telephone. The only thing that I wasn’t able to do, obviously, is do that skin examination for the patient. So, it was very much relying on patients telling us what was going on with their skin. Knowing the patients anyway I found that that was OK ….. and patients are very good at describing what’s going on with their skin as well and I had quite a bit of experience in my role by then so I was able to fully understand what the patients were describing to me.”

Isotretinoin

Isotretinoin clinics are also run by some pharmacists who have specialised in dermatology. “I think this is a good role for pharmacists to do the isotretinoin monitoring for the clinics. It’s really important to have the time to spend with the patients to be able to explain about the medication and the importance of taking it regularly and the importance of doing the monitoring – and especially the pregnancy prevention programme for the ladies of childbearing age. Pharmacists and the specialist nurses are in a very good position to have the time to explain that advice to patients”, says Ms Bryant. Moreover, given that patients enrolled in the pregnancy prevention programme need to have their prescription renewed every four weeks, this provides a natural point for monitoring.

Kläre Bryant is an advanced clinical pharmacist in dermatology at Liverpool University Hospitals NHS foundation trust. She has an outpatient clinic at Broadgreen Hospital for patients receiving biologic therapies and another clinic at Aintree hospital for patients receiving systemic disease modifying anti-rheumatic drugs (DMARDs)

Read and watch the full series on our website or on YouTube.

She says: “Some feedback from one of my patients that just sticks in my mind – he said, “My skin is absolutely fantastic, it’s been the best it’s been for years! I can go out now and wear a pair of shorts and without feeling self-conscious.  It’s absolutely great! I can go out and play with my grandchildren, I can go out in the sun, I can go in the swimming pool and it’s just fantastic! I”m in the best place with my skin that I”ve been for a long time”.”

This patient was taking oral methotrexate together with a number of topical treatments. As with her other patients, Ms Bryant worked with him, over several appointments, to optimise the topical treatments.

A range of topical treatments is used in the management of psoriasis. “Emollients are very important and then we”ve also got the maintenance sort of treatments such as Enstilar, Dovobet and Silkis ointment, which is the vitamin D [analogue] part of the Enstilar and Dovobet”, she explains. Enstilar and Dovobet are used to manage flares of the disease and can also be used when they are needed, and this can be worked out with the patient, she adds.

“Moisturising is very, very important”, says Ms Bryant, but it can be difficult to find the time to apply emollients. “I may advise patients – if they”re struggling – to put the moisturiser on when getting washed”, she says.  After showering or bathing, “when you get out, get yourself dried and [while] the skin’s still a little bit damp, put your moisturiser on, wait a couple of minutes …..”,she suggests. This approach has the least impact on the day-to-day routine and ensures that the moisturiser is applied.  Moisturisers are supplied from the pharmacy but can also be purchased over the counter.  Increasingly, once-daily moisturisers are becoming available. These are ideal because, if applied after a daily bath or shower, that part of the treatment is done. The treatment creams such as Enstilar and Dovobet are designed for once-daily use anyway and can also be incorporated into treatment regimen, she says

Psoriasis treatment can be thought of like “tools in a toolbox” says Ms Bryant. “You”ve got all your tools in the toolbox. You”ve got your tablets – they take the most strain of treating the skin condition – and then you”ve got all your other tools in the toolbox where we”ve got to say we”ll use a bit of some of that or use some of that [and if] that doesn’t quite work then we just maybe switch it around a little bit”, she explains. The key to success is knowing what to use and when. For example, a large tub of greasy ointment to be applied four times a day is unlikely to be used by someone who has a busy schedule of meetings. “We need to work with the patient, with their lifestyle and come up with something that they”re actually going to do and that’s suitable for them”, emphasises Ms Bryant.

Educating patients about how to use their medications to manage their skin disease is also an important part of Ms Bryant’s work. People need to know that “they are allowed to put those medications, with that steroid in, on their skin every day for two or four weeks to get a flare under control. It’s upskilling and educating the patient to know that they can manage their own skin condition by doing that in between appointments – they don’t need to wait to get an appointment with somebody. They are ‘expert patients’; they know they can use those creams [and] topical medications to treat any flares – get on top of it before it gets bad – and then step back down from that and continue with their moisturising. It’s a very much a two-way thing – patients being educated to know what to do and having the tools to do it with”, she explains.

Kläre Bryant is an advanced clinical pharmacist in dermatology at Liverpool University Hospitals NHS foundation trust. She has an outpatient clinic at Broadgreen Hospital for patients receiving biologic therapies and another clinic at Aintree hospital for patients receiving systemic disease modifying anti-rheumatic drugs (DMARDs)

Read and watch the full series on our website or on YouTube.

In addition to routine inpatient work on the dermatology and rehabilitation wards “an extended part of my role is to run my own clinics, one of which is for biologics patients. So, I do biologic monitoring …… I actually monitor the infliximab cohort and also, I do monitoring for patients who are on systemic medications – DMARDs such as methotrexate and azathioprine”, she explains

“Having a skin condition is something that can take over people’s lives”, says Ms Bryant

Part of the problem is that skin conditions affecting the hands, face or scalp are readily visible and can make people particularly self-conscious, for example, if there is rough, inflamed skin on the hands or face, heavy scalp scaling or hair loss. In addition, there can be functional impairment, for example, tight, sore skin on the fingers can make simple operations such as handling coins and credit cards difficult. Similarly, a skin condition affecting the soles of the feet can make it painful to walk.  Simply wearing clothes can be difficult or uncomfortable for someone with inflamed skin, says Ms Bryant. Healthy skin is also important for patients who are about to undergo surgical procedures such as joint replacements or abdominal surgery, she adds.

Ms Bryant says: “It just impacts people’s confidence and so it’s just so, so important and shouldn’t ever be underestimated …….. and we should do everything we can to support them [to] get the best out of their medicines so that they can achieve the very best skin that they can”.

Pharmacy input

Pharmacists can help patients to get the most out their medicines by helping them to work out regimens that achieve the best therapeutic effect with least impact on day-to-day life. “A lot of these things can be messy and smelly and …. they can get on people’s clothing [and] their bedding so we want to help provide lots of advice to patients just with when to use these creams and how to use them so it’s got minimal impact on their life but maximal impact on their skin control”, says Ms Bryant.

Seeing prescriptions for dermatological medications first sparked Ms Bryant’s interest in dermatology and made her curious to know more about the conditions that were being treated. When she saw an advertisement for the position of the dermatology specialist pharmacist, she looked into it and decided to apply for the position.

Kläre Bryant is an advanced clinical pharmacist in dermatology at Liverpool University Hospitals NHS foundation trust. She has an outpatient clinic at Broadgreen Hospital for patients receiving biologic therapies and another clinic at Aintree hospital for patients receiving systemic disease modifying anti-rheumatic drugs (DMARDs)

Read and watch the full series on our website or on YouTube.