In this article you will: • Learn about four common skin problems • Discover how the treatments for these conditions are meant to work • Find out what questions you must ask to ensure that it is safe to supply patients with treatments, and whether you need to involve the pharmacist

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Skin problems can be upsetting – but they can also be a sign of other, more serious things – so counter assistants need to be careful before selling what may seem to be simple harmless treatments  

Scenario 1 Adult acne

A lady aged in her mid-20s comes in and is very upset at her acne, which seems to come and go every month, around her period. You tell her that acne in adults is mainly a problem for women, and is usually associated with hormonal changes, such as her period, early pregnancy, or in some conditions such as polycystic ovary syndrome. It may also be due to medicines, including steroids, lithium (used in psychiatric problems), and in certain hormone treatments.   You tell her you can help but that there are a few things you have to know first: • If she is taking any other medicines • If she has tried other OTC treatments and if these have helped. While you are doing this, you subtly look to see if there are signs of an infection (cracking, pus or a very red colour) and to eliminate acne rosacea, which makes a ‘butterfly' pattern around the eyes, which would mean involving the pharmacist.

Treatments

You know that benzyl peroxide gel or cream is the best thing to try first, and you ask if she has already tried the lowest strength (of 2.5 per cent). You do this because you know the ingredient can cause a skin reaction. You also recommend certain lifestyle measures:     • Washing the face with a gentle cleansing product • Avoiding greasy makeup – instead, use water-based make-up products • Washing make-up off before going to bed • Avoiding touching the skin as this spreads bacteria • Eating a sensible diet with lots of fruit and veg and drinking plenty of water • Avoiding squeezing spots, which can cause scarring.  

Scenario 2 Fungal nails

An older gentleman comes in, complaining that his toe nails have gone all thick and raised, and have turned a brown colour. It doesn't hurt, but he is worried whether his shoes might need changing. You tell him it might be an idea to buy some new shoes. Most likely, the gentleman is suffering a fungal nail infection. Around three people in 100 will get a fungal nail infection at some point, often when they are older. It could be that his shoes are harbouring the fungal spores that are causing, and might restart, an infection. You also suggest that he might get some help with his feet. You notice he had trouble bending down to the lower shelves fixtures, and it won't help him to avoid future infections if he can't bend down to clean his feet, and trim his nails.  

Scenario 3 Corns and calluses

Your friend's mother in law comes into your pharmacy, who you know to be a very active 70-year-old, and often to be found walking in the local park. She tells you her corns are bothering her.   You have a quick peep, and you can see a small, pea-sized area of hard skin on the upper side of her little toe, where the toes meet the leather of the shoes. You agree with her diagnosis. You also spot she has a callus, which is a larger area of thick skin. This is also caused by the skin rubbing against something hard. You know that the elderly often suffer these, as do athletes and anyone who walks barefoot. Treatments Although they are painful, the lady's calluses are not cracked or infected, so they can be treated in the pharmacy. You recommend she looks at your footcare fixture that stocks a variety of products, including creams that soften the hard skin, corn plasters that take the pressure off a painful corn, soft padded insoles to relieve pressure on the underside of the foot, small soft wedges that relieve the pressure between toes, and pumice stones that can be used wear away hard skin. You also tell her that the hard skin of a corn may also be removed using a salicylic acid based paint or gel applied to the affected area. A spot of Vaseline smeared around the corn can help prevent the corn treatment being applied to healthy skin, which it might damage. Finally, you suggest she might like to go shoe shopping – the sales are on, and a new pair of shoes might stop the problem coming back.  

Scenario 4 Athlete's foot

A young teenage lad comes in, and he tells you that his toes on one foot have been itching like mad for a few weeks. He mutters that the skin has gone ‘soggy', and is white and soft, and that there are painful cracks under the toes. You ask him if he has seen any pus or if his toes are very red, which could indicate an infection. You also ask if he regularly suffers from cold feet or if he has had any minor injuries to his feet that have taken a long time to heal. He says no, which rules out more serious conditions such as poor circulation or diabetes. Treatments At this point, you suspect athlete's foot – particularly, as his trainers look well worn, and his socks don't smell too sweet – so you point him in the direction of the athlete's foot fixture, where you sell products in cream, spray, liquid and powder format. You tell him they are all effective and the choice is a matter of personal preference and cost. Some treatments also contain a small amount of hydrocortisone, which is helpful in bringing down redness and swelling. Your colleague, Amanda, who is the senior assistant, also has some wise words to share. She tells the young lad to make sure he washes his feet frequently and thoroughly, and to dry carefully between his toes. Most importantly, he needs to change those shoes and socks more regularly!

You tell him the treatments should work within two to three weeks. If things don't improve, the lad should go to his GP, just to make sure there is nothing more serious going on.  

Key points

• Adult acne can be a very upsetting problem, but is improved by using OTC treatments and by changing the way patients wash and use makeup • The fungal infection athlete's foot should be treated because of the risk that it will spread to the toenails, where it is much more difficult to treat • It is essential to rule out diabetes and poor circulation before supplying treatments for foot problems – if you suspect these conditions are present, customers should be referred to the pharmacist or GP.  

Tips for making the pharmacy a friendly and helpful place

Co-op pharmacist Jane Gormer has some suggestions for making the pharmacy as helpful as possible to patients with skin problems: • Make sure the option of having a confidential chat in the consultation room is well advertised – and use it whenever it's appropriate • Place cleansing products, water-based make-up, and make-up products used for disguising spots and scars on well marked retail shelves – but keep them away from the waiting area in order to reduce customer embarrassment • Stock leaflets about the more ‘embarrassing' conditions: acne, athlete's foot, discoloured and nasty looking nails (which might be fungal), corns and calluses. Leaflets aimed at older people are also useful.  

When to refer foot problems to the pharmacist

Refer to the pharmacist if patients: • have diabetes • have a depressed immune system or are in poor health generally are pregnant • are under 18 years old • have more than one affected nail • If you suspect another condition, psoriasis, which can also cause pitting of the nails.  

Evaluation

• Do you know when to refer skin problems to the pharmacist? • Think how you might help customers choose between different variants? • How can you subtly suggest customers show you their feet, if they don't volunteer? • Remember to be discreet when talking to customers, try to use a quiet area or consultation room.  

Information

NHS Choices: acne www.nhs.uk/conditions/acne/ British Skin Foundation skin information www.britishskinfoundation.org.uk/skininformation.aspx NHS Choices: athlete's foot www.nhs.uk/conditions/athletes-foot/ CKS patient information leaflet:

www.cks.nhs.uk/patient_information_leaflet/athletes_foot NHS Choices: fungal nail infection www.nhs.uk/conditions/fungal-nail-infection CKS Patient information leaflet:   www.cks.nhs.uk/patient_information_leaflet/fungal_nail_infection NHS Choices: corns and calluses www.nhs.uk/conditions/cornsandcalluses CKS patient information leaflet: 

www.cks.nhs.uk/patient_information_leaflet/corns_and_calluses