The specialist dermatology nurse: providing expert care to patients

A ‘Cinderella’ specialty

Dermatology has long been described as a ‘Cinderella’ specialty (Linn, 1956; Bunker, 2013), a term used to describe any under-appreciated, under-funded or under-discussed specialty, including care of older people, mental health, rheumatology, colorectal surgery, hospital dermatology, chronic disease, pain medicine and sexual health. The reason for this attitude towards our specialty is that in the past almost all laypeople, and even many health professionals, regarded skin diseases as dirty, repulsive and abhorrent, a view that dates back to the days when so many skin diseases were due to syphilis, lice, mites, and so on (Linn, 1956). Today, such attitudes persist in some areas and the stigmatisation of people with skin conditions continues (Dimitrov and Szepietowski, 2017).

Skin conditions

The skin is the largest organ of the body and one we all see on a daily basis. But why is it not always given the importance it deserves? The skin tells a story about our patient's health and wellbeing and we can instantly see changes in our patients (Lawton, 2015). Skin conditions affect people of all ages, may be acute or chronic, and can have a significant impact on quality of life. Population data from previous publications have stated that 54% of the population are affected by skin disease, and at any point in time 23–33% of the population report skin disease which would benefit from medical care (Schofield et al 2009; Murphy et al, 2019).

Dermatology involves the management of skin conditions (there are more than 4000) (Murphy et al, 2019) and treating patients from all age groups with inflammatory, inherited, environmental, occupational and malignant skin diseases. Services are predominantly outpatient based, in hospital and community settings. Dermatology teams take referrals from community teams and other specialties, often requiring a multidisciplinary approach with colleagues from rheumatology, haematology, paediatrics, gynaecology and those dealing with infectious diseases, as well as allergists and dietitians. With skin cancer patients, dermatologists also work closely with plastic surgeons, otolaryngologists, maxillofacial surgeons and oncologists. Some patients with acute systemic upset or severe inflammatory skin disease may require specialist nursing input and inpatient facilities (Tan and Chiang, 2011).

Specialist knowledge

Dermatologists and nurses also develop specialist knowledge in specific areas of practice such as paediatric dermatology, phototherapy/photobiology, dermatopathology, allergic disorders, dermatological surgery, skin cancer and chronic disease management and there is also a greater emphasis on dermatology research.

So, as you can see, dermatology is not a ‘dermaholiday’. Many dermatology nurses would have heard comments such as ‘You only apply creams’ throughout their dermatology careers. At the beginning of my dermatology career I worked on a dermatology ward and we did apply messy creams and time-consuming treatments. The application of topical treatments is still a fundamental aspect of dermatological care but is not just a task, it requires a sound theoretical knowledge of the skin and disease processes and practical knowledge of how to assess the skin, recognise the changes associated with the skin condition being treated and evaluate the patient's response to treatments—both those applied to the skin and other therapeutic interventions.

Nurses are now leading the provision of care for many skin conditions. Specialist nurses provide education, patient self-management programmes, manage cases, administer day treatment or phototherapy, prescribe medicines, undertake surgical procedures and look after patients with complex needs to enable them to live at home (Stone, 2016), working closely with community teams. Dermatology nursing is an art requiring many years of practice to develop the necessary skills and knowledge. It is not learnt by reading a textbook or attending a course (Maguire, 2008) and should not be trivialised. In this modern world of social media there is even more focus on how we look and are perceived by others. Imagine having a visible skin condition and how that would affect you on a daily basis (see Box 1 for one patient's description of living with psoriasis).

One patient's experience of living with psoriasis

‘When you meet people for the first time, what do they see but the surface covering? When you go shopping, you wouldn't buy anything that is ripped or dented—you would look for good-quality packaging. Well, that is what it feels like. People see psoriasis and step back. For example, imagine what it would feel like sitting on a full bus and the seat next to you is the only one left. People will stand rather than sit there! It is very demoralising. Think what it feels like when your children beg you not to go to school, to an open evening or sports day, because other children tell them that their mother is “a scabby witch”. Imagine what it feels like to go to the hairdressers and the girl washing your hair goes to put on rubber gloves, after starting to shampoo your hair. Imagine what it feels like not to be able to wear pretty clothes because you can't try them on in the shops because your skin is such a mess and weeps and because the clothes you can wear look awful—long sleeves, high necks, long skirts or trousers and dark colours so the stains don't show. Sleeping in stained “yucky” sheets because of the creams and ointments you have to put on. When your whole life is one long round of creams on, baths off, creams on … and being forever “gunged up”. You get so heartily sick and tired of it all that sometimes you say “stuff it” … and don't bother. Then things get out of hand and your skin gets worse. The worse it gets, the more fed up and depressed you get. The more depressed you get, the worse your skin gets. It's a vicious circle and you can't win.’

The skin is a very visible organ where even small changes in its appearance can impact hugely, so do not dismiss dermatology as a specialty—we make a difference.