Shingles, psoriasis on Vic pharmacy prescribing list

Next month, community pharmacists will be able to manage treatment for mild cases of these conditions.

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While the expansion of Victoria’s pharmacy prescribing trial to allow treatment of shingles and mild psoriasis has the “potential to do good”, “robust and fearless evaluation” of the pilot’s shortfalls will be a must, say experts.

Speaking to The Medical Republic, a spokesperson from the Australasian College of Dermatologists reiterated concerns previously raised with TMR about the NSW pharmacy pilot.

“ACD fully supports pharmacists working within medically led, multidisciplinary team-based settings, however, we do have concerns about pharmacist prescribing models, particularly outside of GP-led team-based primary care setting,” they said.

“Some serious and malignant conditions can masquerade as common diseases of the skin.

“Misdiagnosis can lead to incorrect treatment and dangerous delays to appropriate treatment, and result in patients experiencing significant financial burden due to ineffective treatments.”

Last October, the Victorian government launched its 12-month statewide pilot expanding the roll of community pharmacists.

Initially, participating pharmacists were able to resupply oral contraceptive pills and supply antibiotic treatment for uncomplicated UTIs in women without a prescription from a GP.

Yesterday, Victorian Premier Jacinta Allan announced that the state would begin the next stage of its trial, allowing pharmacists to treat two skin conditions in certain circumstances.

Under the trial protocol, pharmacists may treat adult patients presenting with symptoms of shingles “including a rash characterised by pain and blistering which usually appears on one side of the face/body and does not cross the body’s midline”.

Patients should also be referred to a GP for urgent review in some cases, including patients with unclear presentation, patients with rashes that cross the midline or are near the genitals, those who are breastfeeding or pregnant, those who are vaccinated against shingles and those with other complications.

In the case of symptoms suggesting Ramsay Hunt syndrome the protocol requires referral to a GP or the emergency department.

For adult patients presenting with a recurrence of mild plaque psoriasis in the trunk or limbs, pharmacists can prescribe topical corticosteroids, provide non-pharmacological advice and/or communicate an agreed treatment plan, says the management protocol.

Patients must have a previous diagnosis of psoriasis and have had the initial diagnosis and one acute bout of disease managed with topical corticosteroids by a medical professional.

Patients must be referred to a GP in the case of moderate or severe symptoms, comorbidities or risk factors, including arthritis, depression, risk of venous thromboembolism or signs of cancer, or if their diagnosis has not been reviewed within 12 months.

Pharmacists should refer to a GP and consider specialist referral in some circumstances, such as when the diagnosis is unclear, the patient is immunocompromised, the patient is pregnant or the lesions cover more than 6% of the body or affect the face, scalp, genitals, palms or soles.

Speaking to The Medical Republic, chair of RACGP Victoria Dr Anita Munoz said that while the expansion had “some potential to do good in the community”, it needs “diligent clinical governance and oversight”.

“The health system in its current guise is not meeting the needs of all people in the community, equitably,” she said.

“In particular, patients from vulnerable populations or with difficulty accessing medical services are describing increasing numbers of barriers to managing some medical conditions in the community.”

According to Dr Munoz, this pilot is one of the many “ideas for a better functioning health system” aiming to “improve access for some patients without creating a scope for harm”.

In the name of safety, the Victorian protocols are “conservative”, she added.

But it was important that “that safety is borne out in its practical application”.

“The most important thing with this kind of a pilot is a robust evaluation and independent evaluation.

“Because if a pilot like this is able to do some good and serve the community, then that is good.

“But we also need to be committed to finding problems and either abandoning the pilot if necessary or addressing its limitations or drawbacks.”

The college concurred that “robust and fearless evaluation” was necessary, adding that “it is also important that exploration of these models is not at the expense of investment in addressing both the GP and specialist workforce shortage”.