REVIEW DOI 10.1111/j.1365-2133.2005.06979.

Nurse-led care in dermatology: a review of the literature

M. Courtenay and N. Carey
School of Health and Social Care, University of Reading, Reading, U.K.

Summary

Correspondence Background Nurses play lead roles in the delivery of care in dermatology. While a
Dr M. Courtenay. number of primary studies have been conducted evaluating nurse-led care in der-
E-mail: m.courtenay@reading.ac.uk matology, review and synthesis of the findings from these studies has not been
undertaken.
Accepted for publication
12 June 2005 Objectives To systematically identify, summarize and critically appraise the current
evidence regarding the impact and effectiveness of nurse-led care in dermatol-
Key words: ogy.
dermatology, nurse-led care, prescribing Methods Systematic searches were done of CINAHL, MEDLINE, British Nursing
Index and the Royal College of Nursing Library Catalogue from 1990 until March
Conflicts of interest:
2005. The searches were not restricted to the U.K., and were supplemented by
None declared.
an extensive hand search of the literature through references identified from
retrieved articles and by contact with experts in the field.
Results A total of 14 relevant publications were identified (and included findings
from both primary and secondary care), of which five were descriptions of nur-
sing activities, five were evaluations of nurse interventions and four were patient
evaluations of nurse-led care. The evidence emerging from the literature indicates
that nurses are treating a number of dermatological conditions, primarily using
treatment protocols, across a broad range of clinical settings. However, there is a
lack of confidence among nurses working in primary care (predominantly prac-
tice nurses) to treat some of these conditions (including scalp scaling in psoriasis
and infected eczema). Although the importance of education is recognized, the
educational needs of these nurses are frequently unmet. The benefits of nurse
interventions on service delivery include a reduction in the severity of condition
and more effective use of topical therapies. Patients report faster access to treat-
ment, a reduction in referrals to the GP or dermatologist, and an increase in
knowledge of their condition.
Conclusions Nurses frequently play lead roles in the diverse range of models of care
that exist in dermatology. Although findings of the review are generally positive,
there are methodological weaknesses and under-researched issues, e.g. cost effect-
iveness of nurse-led care, and extended independent and supplementary nurse
prescribing in dermatology, that point to the need for further rigorous evalua-
tion.

Approximately a third (33%) of the population is affected by
skin disease1 and these conditions account for about 15% of a
general practitioner’s (GP’s) workload. Furthermore, 6% of GP
prescriptions relate to the treatment of skin disease and 4% of
NHS retail sales are for dermatology prescription only medi-
cines (POMs).2 Only 5% of patients with skin conditions are
referred to secondary care.3 However, a shortage of dermatol-
ogists, and an increased awareness about therapies and treat-
ments combined with greater expectations among patients,
mean that waiting lists are high.3 There is an urgent need to
improve the quality of care for dermatology patients.
The emphasis placed on the expansion of the role of nur-
ses,4 and the need for staff to work together to reduce waiting
times and deliver modern patient-centred services,5 have
meant that nurse-led services are seen as one means of
improving healthcare provision. There is evidence that nurses
have lead roles to play in the delivery of care in a number of
treatment areas, especially chronic diseases.6–8 Furthermore, it
is evident that the advent of nurse prescribing9 (see Table 1
for a description of the different modes of prescribing avail-
able to nurses) optimizes the role of the nurse in these situa-
tions.10

2005 British Association of Dermatologists • British Journal of Dermatology 2006 154, pp1–6 1
 Table 1 Description of the different modes of prescribing available to nurses

Setting in which
Formulary ⁄ mode of prescribing Type of nurse nurse can prescribe Numbers qualified Medicine ⁄ condition on formulary Description of mode of prescribing
Nurse Prescribers’ Qualified district nurse (DN) Primary and Approx. 28 000 Mainly appliances, dressings, Independent assessment,
2 Nurse-led care, M. Courtenay & N. Carey

Formulary (NPF);
independent prescribing
Nurse Prescribers’ Extended
Formulary (NPEF);
independent extended prescribing
Supplementary prescribing
or health visitor
(HV) (including practice nurse
with a DN ⁄ HV qualification)
Any first level registered
nurse
Any first level registered nurse
(or qualified pharmacist)
secondary care P and GSL medicines, and 13 POMs
Primary and Approx. 4000 Over 200 POMs (including
secondary care controlled drugs),
P and GSL medicines
for over 100 conditions
Primary and Approx. 4000 Whole of BNF. Patients
secondary care (approx. 400 with long-term medical
pharmacists) conditions or long-term
health needs are most
likely to benefit from
supplementary prescribing
diagnosis and prescribing
by nurse from list of
medicines included in NPF
Independent assessment,
diagnosis and prescribing
by nurse from list of medicines
included in NPEF
Patient assessment and diagnosis
by doctor; voluntary prescribing
partnership between independent
prescriber (doctor) and
supplementary prescriber
(SP, nurse or pharmacist) to
implement an agreed,
patient-specific clinical
management plan (CMP);
the CMP includes the list of drugs
required by the patient (and within
the level of competence of SP) that
can be prescribed by SP

BNF, British National Formulary; GSL, general sales list; P, pharmacy; POM, prescription only medicine.

2005 British Association of Dermatologists • British Journal of Dermatology 2006 154, pp1–6

A diverse range of models of care exist in dermatology, par-
ticularly in primary care.2 Nurses frequently play lead roles in
these initiatives.2 An integral part of the optimized dermatol-
ogy service model described in the Action on Dermatology Good
Practice Guide11 is a comprehensive nurse specialist service offer-
ing nurse-led treatment clinics for patients suffering from
common skin conditions. It is advocated that these clinics
should include prescribing by nurses. This review was there-
fore conducted in order to evaluate specifically the impact and
effects of nurse-led care in dermatology to date, and to iden-
tify areas for further research. The aim of the review was to
provide a summary of the current state of knowledge to
inform the policy, education and the practice of nurses work-
ing in dermatology.
Materials and methods
We conducted systematic searches of CINAHL, MEDLINE, Brit-
ish Nursing Index and the Royal College of Nursing Library,
for the period 1990 to March 2005. The searches were not
restricted to the U.K. Key words (alone and in combination)
included: ‘nurse-led’ ‘care’ or ‘clinics’, ‘dermatology’, ‘skin
conditions’, ‘prescribing’, ‘acne’, ‘psoriasis’ and ‘eczema’. The
journals section of http://www.nurse-prescriber.co.uk
(accessed 2 August 2005), a nationally recognized website for
nurse prescribers, was additionally searched. The on-line
search was supplemented by an extensive hand search of the
literature through references identified from retrieved articles
and by contact with experts in the field. The main focus of
the review was primary research. We identified a total of 50
publications. However, many of these were not research based
and provided only descriptive accounts of the nurses’ roles in
a variety of clinical settings and so were excluded. Fourteen
publications met our inclusion criteria. Eleven were primary
research (10 U.K.-based studies and one a Swedish study).
The remaining three papers described audits of practice but
were included in the review as they contained a research com-
ponent evaluating patient experiences of nurse-led care.
Results
Studies were both evaluative and descriptive (see Table 2 for a
summary of study designs) and can be categorized into three
main areas: (i) descriptions of the activities of nurses in der-
matology; (ii) evaluations of nurse interventions on service
delivery; (iii) patient evaluations of nurse-led care. Within
each area, a number of themes were identified. Each of these
themes is discussed.
Descriptions of the activities of nurses in dermatology
The conditions treated
Four studies,12–15 entirely questionnaire based, have been con-
ducted to assess the conditions treated by nurses, the medica-
tions used to treat these conditions, nurses’ levels of expertise

2005 British Association of Dermatologists • British Journal of Dermatology 2006 154, pp1–6
Nurse-led care, M. Courtenay & N. Carey 3
and training needs. Although the numbers of nurses surveyed
across two studies12,13 were small (131 practice and commu-
nity nurses) and the response rate unknown in one study,12 it
is evident that nurses working in primary care treat between
one and five dermatological conditions each week (eczema,
psoriasis, leg ulcers, minor burns ⁄scalds, warts and verrucae
being conditions commonly encountered) and emollients,
antibacterials, topical corticosteroids, keratolytics, tar-based
products, dithranol and antipruritics are the most common
treatments used.14,15
Educational support and confidence
The need for education was reported by the majority of
respondents,12,13 visits to a dermatology department, time
spent with a dermatology specialist nurse and taught sessions
being the favoured modes of learning of those nurses working
in primary care. However, respondents reported that this form
of support was frequently unavailable and that they relied
upon guidance from the GP, medical representatives and self-
directed learning. Self-directed learning was the least popular
method of learning.13 Nurses working in primary care (the
majority being practice nurses) reported a lack of confidence
to treat scalp scaling in psoriasis and infected eczema,12,13
pruritis, skin cancer, impetigo, acne and urticaria.13 Minor
burns ⁄scalds, bites, stings, dressings, allergies, warts and ver-
rucas were areas in which these nurses reported feeling most
confident.13
Clinical context
Nurses involved in the treatment of dermatological conditions
work in a variety of clinical contexts (including inpatients,
outpatients and community settings)14,16 and a large propor-
tion of respondents (77%) also provide advice over the tele-
phone.14 Treatment protocols are the most popular method
(used by 57–77% of respondents) to alter doses of medicines
and initiate treatments.14,16 Dispensing from an agreed stock
and prescriptions with medical countersignatures are other
methods employed. Independent prescribing from the Nurse
Prescribers’ Formulary (NPF) is used in a minority of situa-
tions; however, nurses reported feeling competent to prescribe
independently from a larger range of medicines.14
Cryotherapy is one of the most frequent surgical treatments
performed by nurses.16 Malignancies or lesions are treated by
nurses (normally under supervision) to a lesser extent. Addi-
tional treatments in which nurses are involved include photo-
therapy, wound care ⁄ulcer provision and camouflage and
appliance provision.14
Evaluations of nurse interventions on service delivery
Patient education
Two studies,17,18 one a randomized clinical trial (RCT),17 have
looked specifically at the effects of education and demonstration
 Table 2 Summary of study designs

First author,
year, reference Method Number of participants Status ⁄ age of respondent Condition Primary outcome measure ⁄ question
Broberg, 199017 RCT (2-h nurse education session) 50 4 months to 6 years Atopic eczema Eczema severity; use of topical therapies
Chinn, 200220 RCT 235 6 months to 16 years Atopic eczema QoL
Cork, 200318 Questionnaire 51 Parents of children Atopic eczema Eczema severity
2 weeks to 14 years
Visual analogue 51 (100% response rate) Use of topical therapies
Cox, 199916 Questionnaire 463 (183, 40% response rate) Consultant dermatologists N ⁄A Exploration of clinical settings, treatments
4 Nurse-led care, M. Courtenay & N. Carey

and methods used by nurses working

in dermatology
Cox, 200012 Questionnaire 69 responses (number of nurses Community and practice nurses N ⁄A Condition treated; number of
who received questionnaire unknown) patients; confidence of nurses
Cox, 199815 Documentary evidence; 47 patients Adult patients N ⁄A Types of conditions
medicines supplied
or administered by staff
from a dermatological unit
Questionnaire 45 patient questionnaires Adult patients Patient satisfaction
(33, 73% response rate)
Edwards, 199725 Audit (questionnaire) 30 (33% response rate) Adults and parents of children Eczema Patient satisfaction
Gradwell, 200219 RCT (intervention additional 66 patients 14 and over Psoriasis; eczema QoL
session with a dermatology
nurse specialist)
Jackson, 200014 Questionnaire 395 (277 or 70% responses) Nurses (inpatient, outpatient N ⁄A Exploration of clinical settings,
and community settings) treatments and methods used by
nurses working in dermatology
Kernick, 200022 RCT (nurse or routine care) 100 Adults Eczema; psoriasis QoL
Lester, 200123 Audit (questionnaire) 50 (78% response rate) Parents of children Atopic eczema Patient satisfaction
McEvoy, 200424 Audit (questionnaire) 167 (41% response rate) Adults Eczema; psoriasis; Patient satisfaction
leg ulcers; acne
Penzer, 200021 Questionnaire Unknown Adults Psoriasis QoL
Smoker, 199913 Questionnaire 69 (62, 90% response rate) Practice nurses Condition treated; number of
patients; confidence of nurses

RCT, randomized controlled trial; QoL, quality of life.

2005 British Association of Dermatologists • British Journal of Dermatology 2006 154, pp1–6

of topical therapies by a specialist nurse on the severity of atopic
eczema and the use of topical therapies. An overall increase in
the use of topical steroids was identified by one of these stud-
ies17 and both studies demonstrated a reduction in the severity
of eczema and an increased use in emollients.17,18 These studies
do provide some support for nurse education in addition to
conventional dermatological care.
Quality of life
Four studies,19–22 three of which are RCTs,19,20,22 have exam-
ined the effects of a nurse-led service on the quality of life
(QoL) of eczema and psoriasis patients. Only marginal
improvements in certain aspects of QoL are identified by two
of these studies.20,21 The remaining studies19–22 identify no
such improvements. However, it was reported that patients
who had seen the nurse were more likely to know how long
to apply treatments, how to obtain repeat prescriptions, and
from whom they could receive further support.19 A reduction
in the number of follow-ups seen by the dermatologist was
also cited.
Patient evaluation of nurse-led care
Access to treatment
Evidence from seven studies suggests that patients are happy
with nurse-led services in dermatology. Cox and Walton15
indicate that nurse-led care enables patients to receive imme-
diate treatment as opposed to the requirement of a separate
appointment with a GP or dermatologist. Furthermore,
patients who see a nurse about a previously diagnosed condi-
tion frequently defer an appointment with a GP.
Understanding about the condition and treatment
Three studies17,21,22 report that patients are very positive
about visiting the nurse. Patients feel they have learned some-
thing new about their condition17 and report an increase in
their ability to cope with their condition.23 Other benefits
reported by patients include the provision of advice relating to
the management of everyday problems, information about
medicines, preventative measures that could be adopted to
reduce exacerbation of the condition22 and practical support
with regard to how to apply ointments and creams.23–25
Discussion
The evidence emerging from the literature indicates that nur-
ses are commonly treating eczema, psoriasis, leg ulcers, minor
burns ⁄scalds, warts and verrucae across a broad range of clin-
ical settings. Although there is some evidence that nurses are
prescribing independently from the NPF, there is no evidence
currently available examining extended independent and sup-
plementary prescribing in dermatology and this area requires
urgent evaluation. Treatment protocols are the main

2005 British Association of Dermatologists • British Journal of Dermatology 2006 154, pp1–6
Nurse-led care, M. Courtenay & N. Carey 5
mechanism by which nurses deliver treatment to patients.
There are certain conditions that nurses working in primary
care lack confidence to treat (scalp scaling in psoriasis and
infected eczema) and, although the importance of education is
recognized by these nurses, there is consistent evidence that
the educational needs of nurses working in primary care are
‘unmet’.
A reduction in the severity of the condition and more
appropriate use of topical therapies are benefits identified as a
result of patient education (by nurses) in addition to conven-
tional dermatological care. Only marginal improvements in
nurse-led services on QoL have been identified.21,22 There is
no evidence available examining the cost effectiveness of
nurse-led care in dermatology.
Patient evaluations of nurse-led care report faster access to
treatment and a reduction in referrals to the GP or dermatol-
ogist. Patients also report an increase in knowledge of their
condition and treatment application. They also report that they
are more able to cope with their condition. However, medi-
cines information needs of patients, the effects of this
increased knowledge on treatment adherence and disease
severity are areas that require further evaluation.
Overall study quality was moderate. The research evaluating
nurse-led activities in dermatology, and patient evaluations of
these activities, are predominantly questionnaire surveys, fre-
quently confined to small, convenient samples (and so include
respondents from limited geographical areas) of nurses and
patients. Response rates are generally greater than 60%,
although the possibility of response bias does exist. Further-
more, the generalizability of the findings are limited by the
clinical contexts in which studies have been undertaken and
the patient groups and specialism of the nurse. Several differ-
ent outcome measures have been used in studies evaluating
the benefits of nurse-led care on service delivery. However,
the methodological weaknesses in the majority of these study
designs (including a lack of control group, a lack of blinding
of treatment allocation, small numbers, limited patient groups,
limited outcome measures and short follow-up periods) mean
that caution must be exercised when interpreting findings.
In conclusion, it is evident that nurses play lead roles in the
diverse range of models of care that exist in dermatology.
Although findings of the review are generally positive, there
are methodological weaknesses and under-researched issues,
e.g. cost effectiveness and the use of extended independent
and supplementary nurse prescribing in dermatology that
point to the need for further rigorous evaluation.
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