Re: Conditions for which over the counter items should not routinely be prescribed in primary care: A consultation on guidance for CCGs

In responding to “Conditions for which over the counter items should not routinely be prescribed in primary care: A Consultation on guidance for CCGs Version number: 1 First published: 20 Dec 2017” the BAD recognises the need for financial prudence and the need to prioritise NHS resources on the areas of greatest need.

In response to the consultation we make the following points:

We suggest that the following is added to general exceptions: “any atypical, extensive, debilitating or rapidly recurrent/poorly responsive disease.”

4.1.2 Vitamins and Minerals: additional exceptions where prescribing should be allowed include (1) Zinc supplements for deficiency (can be life threatening in children) (2) Folic acid supplements for those on methotrexate treatment (essential) (3) Iron supplements for treatment of pruritus in the elderly or hair loss in association with iron deficiency.

4.2.2 Cold Sores: “Cold sores” is a loose term and does not equate to herpes simplex infection, which may have many clinical presentations, some serious. We suggest that the term “Mild uncomplicated recurrent cold sore infection of the lip, occurring less often than 2 monthly” should be used. Herpes simplex in those with eczema can result in eczema herpeticum which often requires hospitalisation and can be life threatening. Herpes simplex near the eye can result in permanent loss of vision. Herpes simplex in the genitals is a contagious sexually transmitted disease. Primary herpes infection can on occasion lead to herpes encephalitis which can be fatal. Herpes simplex trigger recurrent Stevens Johnson syndrome and prompt medical treatment or prophylaxis should be available to prevent this.

4.2.5 Cradle cap: This should be re-labelled as “mild cradle cap resolving within 4 weeks”. Both eczema and psoriasis in infants can present with scaling and erythema of the scalp and early treatment of this can prevent deterioration including secondary infection. Practitioners should be advised to treat, or consider referring for diagnostic advice, if these symptoms are not settling after a few weeks or if they are producing distress to the infant.

4.3.1 Contact Dermatitis: We strongly recommend this section is removed. If you prefer to keep this in, then we advise changing the heading to ‘Chapped Hands’ which reflects mild irritant hand dermatitis which should respond to emollients, soap substitutes, minimising wet work and use of gloves where appropriate. The long-term use of topical corticosteroids is not usually required in Irritant Contact Dermatitis and wrong advice could lead to unnecessary side effects. Cases requiring long term or intermittent topical steroids require further investigation to exclude co-existing allergic contact dermatitis or atopic eczema.

The term “contact dermatitis” is confusing because it could refer to allergic contact dermatitis, which along with irritant contact dermatitis, is a common cause of work absenteeism with economic implications. (Politiek K, Oosterhaven JA, Vermeulen KM, Schuttelaar ML. Systematic review of cost-of-illness studies in hand eczema. Contact Dermatitis. 2016 Aug;75(2):67-76.). Potential allergic contact dermatitis requires hospital referral for patch test investigation and if overlooked has legal implications for patients, doctors and employers.

4.3.2 Dandruff: is a loose term referring to scaling of the scalp. It would be better to qualify this with “Mild scaling of the scalp without itching”. This description includes people with mild psoriasis, mild atopic, irritant or seborrheic eczema of the scalp. People with these problems will find benefit from a variety of medicated shampoos and scalp treatments. Antifungal shampoos help only some people with scalp scaling, with others benefiting from other preparations, so the advice should be altered.

4.3.6 Hyperhidrosis: This condition varies in severity. It can be a severely disabling condition. Severe hand sweating can prevent handling of paper, use of keyboards and normal social interaction. It can prevent or severely impair work performance in those who deal with the public or perform intricate manual tasks and cause underachievement in education. People with moderate or severe hyperhidrosis require hospital referral for a trial of iontophoresis treatment, oral anticholinergics or in the worst cases with botulinum toxin injections. The guidance should specify “Mild axillary hyperhidrosis responsive to topical OTC treatments” (reference Health Technology Assessment 2017 21(80) 1-280).

4.3.7 Head Lice: We advise that this should be “Mild head lice infestations without secondary inflammation or infection”. Head lice infestation may lead to secondary eczema or secondary infection. This is often in children from socially deprived areas who require support from doctors and nurses in managing the problem. It is not always a mild self-limiting disease. We also suggest that the phrase “Head lice can easily be treated……” is removed. This is incorrect and could be considered patronising by engaged parents who have spent hours combing the hair of their child with head lice, with little effect.

4.3.11 Insect bites and stings: We advise that this should be changed to “Insect bites and stings received in the UK”. Insect bites from mosquitos and other insects in tropical countries can lead to severe and life-threatening diseases. Malaria is a major preventable cause of death and may be contracted by British people travelling abroad. A note should be made in the guidance that tick bites in the UK can lead to Lyme disease which is a potentially severe illness and should be treated promptly.

4.3.12 Mild acne: There are arguments for removing this section but if left in we advise that this could be “Mild teenage spots” in keeping with the language used elsewhere. Acne is a common cause of significant psychological and psychiatric morbidity in children and teenagers with proven long-term sequelae (Hazarika N, Archana M. The Psychosocial Impact of Acne Vulgaris. Indian J Dermatol. 2016, 61(5): 515–520. Tan J. Psychosocial Impact of Acne Vulgaris: Evaluating the Evidence. Skin Therapy Letter. 2004;9(7)). Many first line treatments in acne, such as topical retinoids, are not available OTC. As acne occurs in up to 90% of teenagers, including acne in this document may encourage teenagers with mild acne, unresponsive to OTC treatment to seek consultation and prescriptions. This could increase pressure on GPs and increase prescriptions. Acne of sudden onset in other age groups may be a sign of endocrine disorder so should prompt investigation.

4.3.13 Mild dry skin and sunburn: This is a confused category and should be split into three. Mild dry skin and sunburn are two completely unrelated problems. The same section then goes on to discuss use of sunscreens which is a further separate subject.

“Mild dry skin” is a reasonable category of disorder to consider for OTC treatment. Dry skin is more common in some ethnic minority groups, so this should be worded so as not to discriminate. A wide range of emollients must still remain available on prescription for treatment of atopic eczema which may initially present as mild dry skin.

“Sunburn due to excessive sun exposure” is a reasonable category for OTC treatment.

“Sunscreen prescribing” is a complex area. There are a range of diseases, referred to in the consultation as the ACBS list, for which sunscreens can and should be prescribed. Our advice is that this range of diseases is updated (table 1) to reflect the full range of diseases causing photosensitivity or high risk of cancer. This full list should be in the exceptions section, indicating where sunscreen can be prescribed.

We agree that it is reasonable to restrict sunscreen prescribing unless individuals have photosensitive skin disease, have a genetic cancer syndrome or are immunosuppressed.

4.3.17 Mouth Ulcers: This is too vague and should be re-designated as “simple single aphthous mouth ulcers lasting less than 2 weeks”. Mouth ulcers may be the first presentation of diseases such as mouth cancer, inflammatory mouth disorders e.g. pemphigus, some serious rare diseases and serious infections.

4.3.18 Nappy rash: Many serious skin diseases can present as nappy rash, so this should read “mild nappy rash lasting less than 7 days”. Failure to improve may indicate that the parents are non-compliant with hygiene practices and use of barrier creams, which may raise child protection concerns, or it may indicate presence of a skin disease such as eczema, psoriasis or a fungal infection requiring further treatment or referral.

4.3.19 Oral Thrush: Correct diagnosis is essential as oral cancer can present with white patches in the mouth. This may also be a sign of serious underlying disease such as HIV or diabetes. Therefore, persistent disease (e.g. over 6 weeks) should be re-evaluated.

4.3.21 Ringworm/athlete’s foot: This contagious fungal skin condition “tinea” can cause severe infection resulting in hospitalisation in healthy children, especially when occurring on the scalp. Tinea between the toes can predispose to recurrent cellulitis, which then can lead to lymphoedema and leg ulceration in old age (Lee ASW, Levell NJ. Br J Dermatol. 2017 Aug;177(2):596-597). Oral treatment is recommended in hair bearing areas. Treatment of contacts with ringworm reduces the risk of serious infections in children. Exclusions should include those with lymphoedema or a history of lower limb cellulitis.

4.3.25 Warts and Verrucae: Occasionally skin cancers on the feet or fingers can be misdiagnosed as verrucae or warts, so a sentence could be added to the guidance saying: “referral for diagnostic advice may rarely be required in cases with unusual presentations causing diagnostic uncertainty and cancer concerns”. There are occasional exceptional cases leading to disability which should be treated.

Download the response as a PDF here.