Dermatology Workforce Service Forecast



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Recommendations

To achieve the vision for dermatology in New Zealand in 2020



that patients will have equitable access to an integrated, consultant-led dermatology service that delivers high-quality health care’, the Group proposes the following recommendations:


  1. Every DHB has a dermatologist-led team providing a core of dermatology services.

  1. All DHBs to have a minimum of 1 full time equivalent (FTE) public dermatologist per 100 000 population.

  2. Dermatology teams to include nurses, a psychologist, GPs, a dermatopathologist and other allied health professionals.

  3. Multidisciplinary clinics held for difficult cases (both dermatoses and skin cancer) in all DHBs or at least at a regional level.

  4. Teams to integrate primary and secondary care, using technology where appropriate.

  5. Patch testing, UV phototherapy, Mohs surgery and expert dermatopathology to be available in all DHBs.

  6. Administration/clerical staff to be provided in all dermatology departments.

  7. Dermatologists to have paid time for their education (continuing professional development) and for providing training to others.




  1. Comprehensive dermatology training provided in New Zealand.

  1. Greater proportion (3 out of 4 years) of specialist dermatology training provided in New Zealand with public consultant posts available at completion of training.

  2. Increase training posts for registrars to 15, to achieve required number of SMOs to fulfil proposed ratio.

  3. Increase number of sites for registrar training from 6 to 10 to include Wellington and Waitemata, with additional posts in Auckland and Waikato.

  4. Use bursaries to fund overseas posts, which are required for dermatology trainees to complete their specialist training.

  5. Recognition of the importance of having appropriately trained and accredited dermatopathologists within each DHB.

  6. Accessible and meaningful accreditation of training for GPs to better manage dermatoses and skin lesions including neoplasms.

  7. Expanded, defined roles and career pathways for dermatology nurses with positions available in all DHBs.

  8. Development of a postgraduate course leading to a Nurse Specialist in Dermatology qualification.

  9. An increased emphasis on dermatology for Pharmacists during training and opportunities for continuing professional development




  1. Dermatology services are accessible equitably across New Zealand.

  1. All DHBs to run a comprehensive dermatology service.

  2. Where appropriate, a hub and spoke service should be run from DHBs, to provide services where there are currently difficulties in access.

  3. Improved access to paediatric dermatology services.

  4. Equitable access to publicly funded phototherapy.

  5. Better availability of, and defined pathways for patch testing and biologic clinics.

  6. National guidelines, pathways and protocols for the management of common dermatoses are developed and incorporated into relevant training and professional development programmes.

  7. Establishment of teledermatology clinics or services where necessary.




  1. Dermatology expertise is enhanced.

  1. Establishing a Centre for Dermatology Expertise, led by one or more professors/senior lecturers in dermatology.

  2. Establishing a network of national or regional subspecialty tertiary services.




  1. The key role of dermatologists is recognised in the management of skin cancer.

  1. Building multidisciplinary skin cancer teams led by dermatologists.

  2. Developing national standards for the treatment of all skin cancers including non-melanoma skin cancer.

  3. Increasing the speed of access to high quality services.

  4. Expanding the current curriculum for all health professionals to include agreed pathways, standards and guidelines.




  1. Better information gathering and data collection.

  1. Workforce data is centrally collected and updated and includes private practice.

  2. Data on incidence of non-melanoma skin cancers should be collected regularly and routinely.

  3. Information on inpatient and outpatients is collected to improve the management of services.

  4. Audits of skin conditions and neoplasms seen and the number of outpatient and inpatient visits, to aid future planning.




Appendix 1: Dermatology Workforce Service Forecast Group

Darion Rowan (Dermatologist, Counties Manukau DHB, Chair)

Steven Lamb (Dermatologist, Auckland DHB)

Deborah Greig (Dermatologist, Auckland DHB)

Martin Keefe (Dermatologist, Nelson & Christchurch)

Weng Chyn Chan (Dermatologist, Middlemore Hospital)

Wee-ling Koo (GP, Cornwall Medical Centre, Auckland)

Karen Agnew (Dermatologist, Auckland DHB)

Ann Giles (Dermatology Staff Nurse, Greenlane Clinical Centre, Auckland)

Barbara Graves (Project Manager)


Appendix 2 Examples from literature (New Zealand and overseas)



Workforce

Dermatology (General)
Several studies in the UK have identified issues similar to those currently being seen in New Zealand.

In 2007, the Dermatology Workforce Groupxxiii noted that too many patients are attending hospital-based services and that any future model of care should concentrate on service delivery governed by three broad statements:



  • Secondary Care Teams should do the things that only they can do,

  • care should be delivered in the right place, by individuals with the right skills and at the right time; and

  • policies should facilitate patient self-management.

It was also noted that service models should be patient oriented and that correct diagnosis is the starting point for quality care. It was identified that primary care should take responsibility for straightforward management of long-term skin diseases and facilitate patient self-management.

The educational role of secondary care should be acknowledged and developed and appropriate educational modules should be developed, to ensure knowledge and expertise of those in primary care.

Multi-disciplinary teams to deliver Dermatology care were identified as central.


In 2008, the Workforce Review Team reported on ‘Workforce Planning for Dermatology in the National Health Service’ xxiv(NHS, UK).

Key points included the need for networked specialist teams to provide care delivery in hospital and community settings.

The report also noted the aging Dermatology workforce and that little work on researching and planning for the Dermatology service has been carried out. Changes to delivery, including the increasing requirements for care in the community and changing GP practice, have led to the service being fragmented.
The British Association of Dermatologists (BAD) carried out an audit of Dermatology service provision, with the focus on the care of those with Psoriasis in 2008xxv. This audit was designed to examine staffing and facilities at Dermatology Departments in the UK. Again, the findings reflect the current situation in New Zealand.
The Royal College of Physicians revised fifth edition of ‘Consultant physicians working with patients’, recommends one Whole Time Equivalent (=FTE) Dermatologist per 62 500 population and that no consultant should work in isolation. Clinical networks should be developed to provide support. Dermatology nurses should be available in all units to support inpatients and outpatients with skin diseases. Clinical psychology should be more widely available. Increased resources would be required to provide for advanced drug therapies such as biologics. Resources should be invested to collect outpatient data to improve management of dermatology services.
In 2011, Primary Care Commissioning UK published a report on ‘Quality Standards for Dermatology’xxvi. This report brings together best practice and existing guidance and aims to meet the needs of commissioners of services in the NHS. Eight standards are identified and are based on overarching principles:


  • that the full range of dermatology services should be accessible at all levels of care and should be developed using stakeholders

  • consistent, high quality care meets independent quality standards (such as NICE standards)

  • people with skin conditions should have their care managed at the appropriate level, acknowledging that this may change over time

  • all dermatology services should be supported by a range of services addressing the wider need of patients, including psychological, social worker and occupational therapists as needed.

The 2009 ‘Health Care Needs Assessment of Skin Conditions in the UK’ xxviiprovides information on the burden of disease, quality of life data and direct economic costs. The range of available services is discussed along with the evidence of effectiveness of services. The Needs Assessment makes several recommendations including:



  • the provision of high quality information and the role of patient organisations

  • patient self care and self management supported by increased training of community pharmacists to enhance treatment and provide knowledge of when to refer

  • advanced training for pharmacists

  • increased dermatology training in the diagnosis and management of common skin conditions

  • all pre-qualification nurses receive a programme that includes information about common skin conditions with relevant post-qualification training to support dermatology nursing in a variety of settings

  • changes to consultant Dermatologist training to reflect population needs

  • development of the role of Specialty and Associate Specialist doctors in teaching of primary health care professionals

  • development of quality of life tools to measure effectiveness of interventions alongside clinical outcomes measures

  • accreditation of dermatology units.

Early in 2013, the specialised services national definition of Specialised Dermatology Specialistsxxviii was commissioned. Specialised services are provided in the UK to serve populations of more than one million people and the definitions help with service reviews, planning and commissioning. This definition outlines the roles, workload, service delivery models and standards required to deliver high quality dermatology and again, emphasises the need for the correct diagnosis, adequate training and staff, multidisciplinary teams, services provided in the right place and at the right time, the need for standards and audits and the need for good communication across professional boundaries.



Consultant Dermatologists
As has been found in New Zealand, the UK has concerns over the future Dermatology workforce. The Royal College of Physicians Census on Dermatology – 2010xxix found that for the first time, female dermatologists outnumbered males, a trend likely to continue. It also found that dermatology has twice the proportion of consultants working less-than-whole-time (35.3%) than the mean value for all medical specialties. It was also noted that although vacancies still exist, numbers of consultant Dermatologists are rising and that Dermatologists work 50% over their contracted time for academic work. The lack of cohesive planning for the workforce was also highlighted.
The revised 5th edition of ‘Consultant physicians working with patients’ in 2013xxx notes that Dermatology care is carried out most efficiently in the UK using a hospital-based team led by a consultant dermatologist, with Staff grade and Associate Specialist (SAS) doctors, GPs and nurses in secondary and integrated intermediate care. Multi-disciplinary teams in skin cancer clinics involve dermatologists, surgeons, histopathologists, oncologists, radiotherapists, nurses, and psychiatrists and psychologists. Combined clinics between dermatologists and hospital specialists exist for complex problems, e.g. involving rheumatology, plastic surgery, HIV, genital/oral diseases, psychiatry, paediatrics, genetics, stomas, eyes, vascular surgery and allergy.

Dermatology Nursing

The definition and scope of Dermatology nursing is not consistent, or even evident, in many countries. Through contact with the Dermatology Nursing Education Australia and the British Dermatological Nursing Group, it was found that both organisations are currently working on this.


The UK has recently developed general competencies for nurses working in Dermatologyxxxi and is currently working on developing standards. They also carried out a workforce survey, which identified three key issues.

  • The need for dedicated dermatology departments allowing patients
to access specialist care from a multidisciplinary team. This includes dermatology-trained nurses with appropriate skills for treatments and management of patients with dermatological conditions.

  • A nationally recognised post-registration dermatology qualification in managing patients with skin disease to enable nurses to work within a nationally recognised competency framework at a level appropriate to their area of work.

  • Patients to have access to clinical psychologists with the knowledge and expertise of managing patients living with skin disease. To have easy access to refer patients from both medical and nursing professionals will help to support patients and give them skills to manage their skin disease from a psychological perspective.

The Dermatology Nurses Association (USA) has a defined ‘Scope of practice’ and ‘Standards of Clinical Practice’. The scope of practice uses the framework of core, dimensions, boundaries and intersections to inform practitioners, educators, researchers and administrators as well as other health professionals and the public. The Standards of Clinical Practice are to provide definitive direction for the provision of care and professional role activities of dermatology nurses, through assessment, measurable outcomes and nursing interventions customized to meet the needs of the individual.

Several UK reports highlight the importance of nursing in dermatology care delivery and the currently unmet potential of nurses to provide education to patients and other health professionals, to take on increased roles, to administer therapeutic regimes and to coordinate care. A solution to the lack of dermatologists worldwide was seen as providing effective delivery by nurses as part of multidisciplinary teams, community outreach and management and self-management of skin conditionsxxxii.

Another report highlighted the integral role that nurse-led care provides to dermatological services and noted that nurses are currently providing treatment in a broad range of settings. Where nurses were involved, patients reported faster access to treatment, reduced referrals to GPs and increased knowledge of their condition. Again, the lack of educational opportunities for nurses was cited.xxxiii

A questionnaire-based study of ‘The expanding role of nurses in surgery and prescribing in British Departments of dermatology’ xxxivfound an anticipated increase in nurse-run clinics and a wide variation in nurses prescribing and administering treatments. Obstacles to extending nursing roles were seen as opposition from administration or nursing hierarchies, funding and uncertainties from the nurse themselves. Dermatologists supported the development of increased roles, as long as they were provided with adequate training protocols and staff support.

Advanced nursing roles, where nurses take on a range of procedures more commonly provided by other health professionals are outlined in several studies. The article ‘Biological Nurse Specialist: goodwill to good practice’xxxv notes that with additional training, the specialist nurse may take responsibility for a number of tasks in the patient pathway including screening, treatment administration, patient education, prescription coordination, patient monitoring and data collection. The report also notes that nurses trained to deliver increasingly widely used biologic therapies are of great benefit to patients and central to the operation of multi-disciplinary teams. However it is also noted that they need to have in-depth nursing knowledge built on a foundation of biologic therapy and disease activity.

Two American papersxxxvi,xxxvii which considered the role of nurse practitioners in the assessment and referral of skin cancers, again highlighted a lack of measurement of barriers. A lack of time was cited as the most common barrier. Recognition and referral of skin lesions was inconsistent, but improved over time. There are few skin cancer training programmes available for Advanced Practice Nurses, but these need to be put in place to increase the skills needed and to enhance the role that nurses can take on in the assessment and management of skin cancers.



General Practice

In 2011, the Department of Health in the UK revised the NICE (National Institute for Health and Care Excellence) ‘Guidance and Competencies for the provision of services using GPs with Special Interests (GPwSIs): Dermatology and skin surgery’. xxxviiiThis framework was developed by a multi-disciplinary team including specialists, GPs and patients. It is designed to help dermatology GPwSIs understand and develop the extended knowledge and skills they require to provide services beyond the scope of their generalist roles. The Royal College of General Practitioners has developed accreditation based on this framework.

The key points of these guidelines are that the training and development of GPwSIs will require the on-going support from Dermatology specialists. Improving diagnostic skills is essential, but the core activities of the GPwSis will depend on the resources and skills of the GP. The service would be required to be supported by suitable trained dermatology nursing, necessary facilities and equipment, links with dermatology and histopathology departments, administrative support and good record keeping, including photographs.
This guidance should be read in conjunction with:

‘Implementing care closer to home: Convenient quality care for patients Part 3: The accreditation of GPs and Pharmacists with Special Interests Supporting Q&A (2007) and providing care for people with skin conditions: guidance and resources for commissioners’ (NHS Primary Care Commissioning 2008)


In New Zealand, several regions are working on developing GPs with a special interest in skin lesions and/or developing skin lesion pathways.

The skin lesion GP service in Otago has been running for approximately four years, and has seven trained GP practitioners. The service receives referrals from primary care, mostly for suspected skin cancers, and is contracted by Southern DHB to perform 350 procedures each year. Under this service, patients can still be referred to secondary care clinicians when required; however, because of referrer knowledge of the service, and the level of expertise and experience GPwSIs have developed, 99 percent of referrals are managed by the trained GPs. The service was reviewed in 2012.xxxix The benefits of the scheme are:



  • Reduced waiting times for treatment: the average waiting time from referral to treatment for minor surgery was 12.3 days in 2010/11.

  • Increased capacity, quality and range of services delivered in primary care and reduction of unnecessary referrals to secondary care.

  • A quality, timely service provided at no cost to patients close to their home.

  • Improved integration and communication between primary and secondary.

  • A valuable opportunity for GPs to develop new clinical competencies and undertake a greater variety of clinical activities.

  • Reduced waiting times for patients and reduced administration for the service, and a higher conversion ratio from referral to surgery with referrals from the GP skin lesion service.

Key learnings are noted as:



  • Before developing services that are appropriate for specific community needs, DHBs considering establishing such GP services should undertake a comprehensive assessment of current patient flows, capacity, demand and community health need.

  • Establishing quality services requires the synchronisation of technical, administrative and clinical expertise in both primary and secondary care. Delivering services in the right place at the right time by the right people to the right patient will result in improved quality of care for patients, improved staff satisfaction and a more cost-effective and efficient service.

  • Clinical prioritisation based on patient need and ability to benefit relative to other patients referred, is a fundamental requirement of all publicly funded elective services. DHBs need to develop access criteria linked to available capacity, which ensure services are provided to patients with the greatest need.

  • In order to maintain clinical competencies and sustainable service delivery, GPs need to work with a minimum number of 50 referrals per year and preferably 100.

In Christchurch the Canterbury Initiative have been running a programme for the last few years in which GPs are trained in skin surgery techniques by the plastic surgeons.  Once accredited, they receive a subsidy to excise skin cancers from public patients who would not otherwise be able to afford treatment in primary care.  Accredited GPs can take referrals from colleagues.  The programme is carefully audited to make sure that most of the lesions excised are indeed skin cancers and that excisions are done satisfactorily.  The scheme has proved popular and effective.


A recent report released in the UK notes that, in the UK, ‘GPs with a special interest (GPwSI) in dermatology can provide effective intermediate care for individuals with chronic mild/moderate inflammatory diseases, skin infections, sun damage and certain skin cancers as part of an integrated consultant dermatologist-led team. There is no good evidence that these services reduce secondary care referrals or save money; they may ‘de-skill’ GP colleagues. There are detailed Department of Health safety, governance and training guidelines for the accreditation of GPwSIs, which some primary care trusts (PCTs) ignore, risking patient safety’.xl

Pharmacists

In many countries, including New Zealand, pharmacists can undertake continuing professional education on a range of subjects related to Dermatology.

In 2013, in New Zealand, the Medicines (Designated Pharmacist Prescriber) Regulations 2013 was introduced in July 2013. This enabled the introduction of a scope of practice for pharmacist prescribers.

Scope of Practice

Under the Health Practitioners Competence Assurance Act 2003 the Pharmacy Council (the Council) must publish a description of the contents of the profession in terms of one or more scopes of practice. The Council has developed the competence and registration requirements for the Pharmacist Prescriber scope of practice. In this scope suitably qualified and trained pharmacists who are already working in a collaborative health team environment will be able to prescribe medicines.

Dermatology is not currently listing as an area of practice.
Dermatology service
One of the Group was involved in the establishment of community dermatology (Intermediary care) in the UK. This was part of the ‘Care closer to home’ initiative. The proposal included primary care, specialists and nurse specialists.
This was intended to lead to a cheaper service, bringing consultants closer to GPs and with an educational component, providing a hot line to the consultant. The service involved consultants, GPWSis and specialist nurses.
This was seen to be cheaper, and more accessible patient care, having the service clinic based and with a limited criteria for treatment. It was good for the GPs as they were working closely with the consultants and were gaining training at the same time.
The consultants felt it was good to work more closely with the GPs. In this instance, the specialist-nursing role, as first point of contact with the service, didn’t really work, as the nurse did not know all the dermatological conditions. The role of specialist nurse worked well when given specific tasks such as skin biopsies and providing patient education, rather than in a general clinical role.
Paediatric Dermatology

In 2012, The British Association of Dermatologists and British Society for Paediatric Dermatology produced the ‘Working Party report on minimum standards for Paediatric Services’xli. The aim of this report was to provide a consensus statement for the provision of paediatric dermatology.


Again, multidisciplinary teams were recommended, based in appropriate child-friendly facilities with high levels of information and choice for parents. In addition, basing the service on the needs of the child, rather than the child fitting in with the existing services was highlighted. Detailed information provided includes descriptions of services, pathways, referral management, staffing requirements and training, facilities, education, procedures, administration, prescribing and governance.
Two New Zealand studies looked at children with specific dermatological conditionsxlii A longitudinal study of the prevalence of childhood eczema showed that it remains a significant problem, particularly for young Māori and Pacific New Zealanders in whom less recognition of eczema and poorer access to effective, sustained eczema management may be contributing factors. A study of serious skin conditions in the Tairawhiti region found that serious skin infections are an increasing problem for all New Zealand children, but incidence rates in the Tairawhiti region are consistently greater than average national trends, with significantly larger ethnic disparities.
Teledermatology

In the UK, ‘Quality Standards for Teledermatology’ xliiihave been produced. This document compares teledermatology to face-to-face consultations. Three levels of teledermatology are described – as a triage tool, as ‘full teledermatology’ where it is offered as an alternative to a face-to-face consultation and intermediate teledermatology – which combines both of these approaches.

A case study in the UK in 2012xliv described a service that used teledermatology to avoid unnecessary referrals and improve the quality of care for patients usually seen in primary care settings. The study showed that the service was effective in preventing avoidable attendances at secondary care, delivered financial savings, reduced the time for patients to receive specialist opinion and was popular among GPs. The British Teledermatology Society describes teledermatology in the UK, shares best practice and provides educational opportunities and information on setting up services.

In New Zealand, a Clinical Research Seminar with the title ‘Improving access and grading evaluations using in-depth teledermatology: image it trial’ found that:



  • there was excellent concordance between face-to-face and teledermatology diagnosis for all lesions with only a 6-7% significant difference

  • of all lesions referred, there was potential for >80% of all lesions to be managed by the General Practitioner

  • the results of this study showed that teledermatology can be used as a triage tool to improve healthcare access and delivery.

Contact Dermatitis and Patch Testing

In 2009, the British Association of Dermatologists produced an update to the ‘Guidelines for the management of Contact Dermatitis.’ xlv The recommendations in these guidelines are:



  1. Patients with persistent eczematous eruptions should be patch tested.

  2. A suggested annual workload for a patch test clinic serving an urban population of 70 000, is 100 patients patch tested

  3. Patients should be patch tested to at least an extended standard series of allergens.

  4. An individual who has had training in the investigation of contact dermatitis prescribes appropriate patch tests and performs day 2 and day 4 readings in patients undergoing diagnostic patch testing

Minimum standards include; a lead dermatologist for the unit, who attends regular training, best practice guidelines being followed, electronic gathering of information with audits and up to date reference material.

Skin Cancer

A report to
The Cancer Society of New Zealand in 2009 “The Costs
of Skin Cancer to New Zealand’ notes that



  • Skin cancer is by far the most common cancer affecting New Zealanders.

  • There were 18,610 new cancer registrations in 2005.

  • Of these 2,017 were ‘Malignant melanoma of skin’; 10.8 percent of all cancer registrations.

  • Non-melanoma skin cancers are not registered. If, however, an estimated 67,000 new non-melanoma skin cancers per year are added, new skin cancer cases each year total about 69,000; and all new cancers about 86,000.

  • Skin cancers account for just over 80 percent of all new cancers each year.

Skin cancers fall into two types, Melanoma and Non Melanoma Skin Cancer (NMSC).

In New Zealand, The Ministry of Health are about to launch Melanoma Tumour Standards as part of a wider tumour standards initiative, designed to:



  • ensure patients receive the same standard of care regardless of the DHB area or region they live in

  • enable the development of efficient and sustainable best practice management of specific tumour types

  • promote a nationally coordinated and consistent approach to service provision for the tumour type.

Several regions of New Zealand are working to develop skin lesion pathways (Hawke’s Bay) and the Wellington Sub-region has an established Melanoma Multidisciplinary Team based at Hutt Hospital, with an established protocol for management of melanoma.

In 2006, the NICE guidance ‘Improving Outcomes for People with Skin Tumours including Melanoma ‘(UK)xlvi on skin cancer services, outlines how healthcare services for people with skin tumours should be organised. The key recommendations include:



  • Cancer networks should establish two levels of multidisciplinary teams to care for patients. 


  • Patients with a precancerous lesion should either be treated by their GP or referred.  


  • Patients who need specialist diagnosis should be referred to a doctor trained to diagnose skin cancer. 


  • Skin cancer teams should work to agreed protocols.

  • Protocols should cover the management of care for people in high-risk or special groups. 


  • Follow-up care should be agreed. 


  • All patients and carers should have access to high quality information. 


  • Information should be collected. 


  • More research should be done.

These guidelines were reviewed in 2010 when NICE published a partial update of this guidance. Recommendations and text relating to the management of low-risk basal cell carcinoma (BCCs) in the community have been removed from the 2006 guidance and replaced by 'Improving outcomes for people with skin tumours including melanoma (update): the management of low-risk basal cell carcinomas in the community'.

An analysis of the potential economic impact of the guidelines was also produced in 2006, to illustrate the costs to service commissioners of providing the recommended services as per the guidelines.

The ‘Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand’ xlviiproduced by the Cancer Council Australia, Australian Cancer Network and the Ministry of Health, New Zealand in 2008 recommends that:



  • prevention is important

  • appropriate interventions are required

  • early detection and accurate diagnosis, by trained health professionals is vital

  • awareness of cultural differences is important

  • access to histopathology is imperative

  • psychosocial support is provided

  • population based screening is not supported

  • communication is very important

  • high risk patients should be identified

  • multidisciplinary teams are appropriate

Home Phototherapy

Two articles in the British Medical Journal support the delivery of home-based phototherapy as a treatment option. An editorial in the British Medical Journal (BMJ)xlviii ‘Home UVB phototherapy for psoriasis’ refers to a pragmatic study that compares home UVB with outpatient UVB as part of normal clinical practice. The study highlights an important gap in the provision of treatment for patients with psoriasis. With new potent, but costly, biological treatments now widely available for moderate to severe psoriasis, it is timely to reassess conventional treatments such as UVB. It would be inappropriate for patients to receive these new and expensive treatments when the infrastructure to deliver well established cheaper treatments, such as UVB, is lacking.


Dermatologists should reflect on the shortcomings of current phototherapy services, where many patients are excluded because they live too far from their local unit. The case for home provision of UVB phototherapy for psoriasis is most persuasive in sparsely populated areas. Experience in Germany, the US, the Netherlands, and Scotland confirms that it would be feasible and practical to implement home based UVB phototherapy.
The study referred to in the editorial, Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study)xlix, found that Ultraviolet B phototherapy administered at home is equally safe and equally effective, both clinically and for quality of life, as ultraviolet B phototherapy administered in an outpatient setting. Furthermore, ultraviolet B phototherapy at home resulted in a lower burden of treatment and led to greater patient satisfaction.
In the USA, the National Psoriasis Foundationl note that home phototherapy is an economical and convenient choice for many people. Like phototherapy in a clinic, it requires a consistent treatment schedule. Individuals are treated initially at a medical facility and then begin using a light unit at home.

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