The Role of the Pharmacist in Acne Treatment

Ravina Sanghera, Pharmacist – Edmonton, AB

Now that we know that pharmacists can diagnose and treat mild to moderate acne, how do you see pharmacists contributing to acne management beyond the dispensing of medications?

We know that inequities in the health care system exist, and dermatology is not separate from that. And one of the contributing factors to that inequity in dermatological care is the fact that patients don’t have timely access to a specialist who can help them manage their conditions.

We know that pharmacists are one of the most accessible healthcare providers, and with the broadening scope of pharmacists, we are positioned to help patients access effective care early on.

And so can you talk to us a bit about the benefits of these changes, allowing the pharmacists to diagnose and treat acne, and the benefits specifically to the patient, to the pharmacist, and to the dermatologist?

So it was long thought that acne is only perhaps skin deep, that it was a cosmetic issue. And more and more research has shown, as well as patients sharing their lived experiences, that acne goes beyond just the impacts on the skin.

It can affect your psychological well-being and your ability to form relationships because acne can become all-encompassing. So, going long periods without treatment or not knowing your options, it’s unnecessary suffering for the patient.

So, if a patient can access a healthcare provider to help them navigate their condition sooner, then there’s less of an impact on the patient when it comes to those psychological impacts.

I think the benefits, as you said, are not just to the patient, but to the timelines sometimes associated with access to a dermatologist. These changes can either eliminate that altogether, or potentially give folks that kind of stopgap while they wait for additional treatment.

Absolutely, a pharmacist can serve as a bridge: when they are seeing a specialist, perhaps they’ve already explored some other options, and they can actually step up therapy instead of starting from the ground up again, which can be frustrating for the patient.

As the pharmacy landscape and our scope have broadened, our curriculums in pharmacy education have evolved as well. Our students are well equipped to be that primary access point for patients when it comes to managing their acne.

They are not only learning about all the innovations in terms of acne options when it comes to medicine or cosmetic procedures, but they’re actually getting practice developing a care plan for patients and utilizing the best approach that meets the patient’s needs. So they’re getting practice in their curriculum, and that’s translating to really good patient outcomes when they are in practice.

So when we talk about folks having this knowledge that they can now talk to the pharmacist about their acne, what does the process look like when someone approaches the pharmacy counter looking for acne treatment or advice?

The ability of pharmacists to be involved in a patient’s care plan for acne may differ slightly from province to province. But one piece that’s foundational is that we start with a conversation. We try to get a really good understanding of the impact of the condition on the patient, what their goals are in terms of their treatment, and what they’ve tried.

And if we can’t implement the ideal therapy at that point as a pharmacist, we can definitely help bridge them to appropriate care.

So it starts with a conversation and working with the patient to achieve the goals they have for their acne.

So, if it’s determined that a patient does need to see a dermatologist, can the pharmacist make that referral, or do they have to go back through a family doctor or clinic?

So in some provinces there may be that direct referral pathway, but it’s not consistent. However, at a minimum, pharmacists have the ability to contact a patient’s family doctor, put in a recommendation, and help navigate that pathway.

So if we cannot prescribe the medication that is best for the patient at that time, we can at least help form a bridge to them acquiring the therapy or the care they need. And that’s a good step.

Across Canada, we’ve come a long way as pharmacists in terms of implementing timely care; there are many tools in our toolkit that go beyond over-the-counter medications. So I’d encourage patients to reach out to a pharmacist. We can help work with them to make an informed decision on what that next step may look like.

Given your role in a faculty capacity, can you tell us how acne management is currently taught within the pharmacy programs, and how has it changed since this new scope of practice has been implemented?

Absolutely. So pharmacists need a good understanding of what contributes to the development of acne. We need to have a good understanding of what questions to ask so we can really get an understanding of the impact that acne has on a patient.

In addition, we need to stay well informed of the advancements in therapeutic options. I mean, when I think about all the tools in my dermatology toolkit, I went from having maybe two or three products that were over the counter to maybe having 20 or 30 topical options right now.

But with the broadened scope of prescribing, I have access to prescribing those really effective medications. So our students are well informed and knowledgeable about options. They know how to communicate with patients. They know how to develop a care plan, but they also know when to follow up or when they need to refer further if we’re not achieving the outcomes we need to.

So not only do we learn this in the classroom, we have labs where students are working with mock patients to really practice those skills, so when they are out in the real world, they’re as effective as they can be.

Since this is fairly new, how do you see the pharmacist’s role in acne treatment evolving in the coming years?

I’ve seen a huge shift in terms of access. Acne is one of the primary reasons why patients seek the advice of a family doctor or a dermatologist when it comes to skin disease.

We also know in our current health system, the lag that occurs in accessing a physician or a dermatologist. So even now, we’re seeing an increase in the number of patients who are going to the pharmacy as their first stop.

In terms of evolving, I think the scope will continue to broaden where we can prescribe more medications in different provinces. In Alberta, we have the privilege of being able to prescribe without very many limitations, but I know that doesn’t translate to other provinces. So I hope to see other provinces catch up in that regard.

If we’re well-informed in terms of how these drugs are supposed to act, and how to monitor safety and efficacy, I think we can broaden our scope of prescribing across Canada, so regardless of which pharmacy a patient goes to, or in which province, they’re still getting the same consistent level of care.

So, what guidance, then, do you give to students about discussing sensitive conditions, like acne, with empathy, but also professionalism?

So that relationship with the patient is foundational to any other work you’re going to do with that patient. If that person has trust with you, they’re going to divulge information that is crucial for you to really tailor that care plan and be a partner in their journey of seeking medical care.

So that takes time, that takes an open mind, that takes understanding of their values and beliefs, and inviting the patient to share what they may have tried in terms of their acne journey or treatment journey.

We are a diverse society, and we sometimes default to Western medicine as being the only way, and sometimes patients will not divulge the other alternative approaches they may be taking.

Those alternative approaches may be actually benefiting their acne treatment plan, but they don’t want to divulge that, or it may be exacerbating their current acne state. So if we don’t have an understanding of the full breadth of what they’re doing to manage their condition, we can’t tailor an accurate care plan.

So, trust building is very important, inviting the patient to share their beliefs and values, so you can really get that effective, accurate care plan that is tailored to their needs.

How do you think pharmacist-led acne care will affect not only patient access, but also the outcomes?

So with a lot of skin disease (like acne), to get better success in terms of management, timely care is paramount. We know there can be complications that arise, and so it’s not about just timely access; it’s about having access to effective care early.

Originally, when pharmacists didn’t have the broadened scope that they do now, we were limited in terms of efficacious therapy, or a therapy that was really highly effective that could be offered to patients. So patients were suffering unnecessarily until they could see a physician or a specialist to prescribe that therapy. And when that unnecessary suffering is prolonged, there are other complications that we end up dealing with.

For example, in those with skin of colour, sometimes the skin conditions don’t present exactly as one would think because we are biased towards seeing skin conditions just on one or two skin tones. And those are usually lighter skin tones.

Acne, for example, presents differently on black and brown skin and potentially doesn’t get picked up as soon as it could, increasing the risk of complications. So in black and brown skin, one of the complications is hyperpigmentation or hypopigmentation, which can take months to manage. So it’s not just the acne itself; it’s the resulting complications from it that may also need to be addressed, because the patient didn’t have access to timely or effective care.

Pharmacist-led acne care can change that.

That’s another great example of how the pharmacy curriculum is evolving, I guess.

Yes, that’s the point. So when it came to education in the pharmacy program, we have a responsibility to stay informed of how these conditions may present on different skin tones and what considerations need to be taken into account when tailoring therapy.

Because therapy for one skin condition on one skin tone may not translate to another patient and how they’re presenting.

We know that hormones play a big part in acne, but how does that relate to age? So in terms of acne treatment for a teenager with hormonal acne as opposed to a perimenopausal woman with hormonal acne, for example.

How acne is now presenting in different age groups and demographics is kind of shattering the earlier literature, where it felt like the diagnosis of acne was really contained to a certain age demographic – teenagers – and it was framed as, “it will go away once you’ve gone through puberty.”

And we know from listening to patients and seeing what’s happening in our community, that isn’t always true. So, we cannot get boxed into thinking of management of these conditions in one way. Because our communities are so diverse, right?

You have it at multiple stages of the life cycle. We have teens who are self-conscious and dealing with self-esteem issues, as well as women who are going through perimenopause, who had great skin for most of their life, and all of a sudden, they don’t recognize their body, their skin, and the changes that are happening, and they don’t know where to start.

Pharmacists are in an ideal position to help educate patients and inform them of their treatment options. And we, as pharmacists, have a responsibility to stay on top of the research and the approaches to treatment in all age groups and all demographics.

And that is how our curriculum is evolving as well.

So many women who are experiencing that perimenopausal hormone shift are really struggling with their skin. And there’s a mental health or psychological impact to that, right?

Absolutely. Pharmacists are also in a position to debunk myths.

We are vessels for information or accurate information. So we welcome questions from patients.

There are some patients that I’ve spoken to who blame themselves when it comes to the development of acne. What did I do wrong? What am I eating wrong? Or it can be considered a hygiene issue. Am I not clean enough?

Those are all myths, so we are also conveyors of accurate information, so we can really partner with the patient in getting access to the care they need, so they feel good about themselves, and feel good about how they are being managed with their condition.