CARE PLAN

ITEM: 	GP Management Plan  ____ 721	
	TCA    ____ 723                                                     

PATIENT DETAILS: | GP DETAILS:
[Patient Demographics:Full Details] | [Doctor:Full Details]
DATE CARE PLAN PREPARED: [Miscellaneous:Date]
PROBLEM LIST:
[Clinical Details:History List]

ALLERGIES:
[Clinical Details:Allergies]

CURRENT MEDICATIONS:
[Clinical Details:Medication List]

[Clinical Details:Measurement BP]

[Clinical Details:Measurements]

CARE PLAN TEAM MEMBERS or if GPMP - SERVICE PROVIDERS:
NAME | TYPE OF CARE | if developing a TCA CONTACTED/ COPY SENT | if developing TCA AGREED?
[Doctor:Name] | GP (details above) | yes | yes
[Addressee:Full Details] | [Addressee:Specialty] | yes | yes
 TCA for cardiovascular disease – stroke / coronary heart disease / peripheral vascular disease

GP MANAGEMENT PLAN: dermatitis

Patient problems / needs / relevant conditions | Goals - changes to be achieved (if possible) | Required treatments and services including patient actions | Arrangements for treatments/services (when, who, and contact details)
1. General | | |
Patient's understanding of dermatitis | Patient to have a clear understanding of dermatitis and the patient's role in managing the condition | Patient education | GP

Diagnosis of dermatitis

Patient to undergo clinical assessment

Acute phase
Oedema and crusting
Oozing and weeping

Chronic phase
Fissuring and scaling lichenification

Other features

Itch / excoriation
Hot red skin
Secondary infection
Impairment of thermoregulation

Types of eczema 

Endogenous - intrinsic - types include:

Atopic eczema
Discoid eczema
Pompholyx
Seborrhoeic eczema
Asteotic eczema
Pityriasis alba
Actinic dermatitis
Exogenous - extrinsic - types include:

Contact dermatitis - primary irritant or allergic contact
Photodermatitis
Phytodermatitis
Photophytodermatitis
Hypostatic or varicose eczema
Lichen simplex
Autosensitisation dermatitis

In asteotic eczema the skin is degreased and dries out. Predisposing factors are:
Overwashing / overscrubbing - especially in situations of community care
Inadequate removal of soap
Low humidity / dry air - central heating; hospital winter diuretics

GP / other specialist

Testing in dermatitis

Patient to undergo appropriate clinical testing

Serum IgE levels - elevated secondary to loss of suppressor lymphocyte activity

Skin prick tests - positive to common allergens Skin prick testing: immediate hypersensitivity testing.
False negatives with concurrent administration of antihistamines
Risk of anaphylaxis

Radioallergosorbent testing (RAST) / allergen specific immunoglobulin- suggest that IgE is synthesised against the specific antigens of the house dust mite, pollens, cat and dog hair, food allergens

Skin biopsy reveals chronic inflammation involving lymphocytes, mast cells, histiocytes, eosinophil degranulation

White dermographism - rubbing skin elicits a simple white linear streak along the site of pressure with no erythema

GP / other specialist

Assessment of red flags for dermatitis

Patient to undergo appropriate clinical assessment to exclude serious differential diagnoses of dermatitis

Red flags

Acute 
Superimposed bacterial infection
Superimposed herpes simplex infection – eczema herpeticum

Chronic 
Differentials include
Mycosis fungoides
BCC
SCC

GP / other specialist

Complications

Assessment of complications of dermatitis

Sleep disturbance 
Psychological problems including anxiety and depression
Reduced performance at school or work

GP
Other specialist
Psychologist

Control of allergens

Minimisation of symptoms by the control of exposure of patients to allergens identified as triggers for symptoms

Provision of information relevant to control of allergen exposure.

GP 
Other specialist

Avoidance of triggers

Minimisation of symptoms by the control of exposure of patients to allergens identified as triggers for symptoms

Provision of information relevant to control of triggers
E.g. 

Avoidance of irritants
Personal protective equipment
Gloves / Non-latex gloves
Powder free gloves

Avoidance of skin dehydration
Central heating – dry heat 
Frequent washing 

Use of soaps and detergents

GP / other specialist

2. Lifestyle / conservative management | | |

Nutrition

Optimising health

Healthy eating pattern, low fat diet Patient education

OR 
As per Lifescripts action plan

GP to monitor 
Patient to implement
Dietician to advise

Weight

Normal weight to optimise health

The provision of dietary advice aimed at controlled weight loss and the setting of weight loss targets aimed at improving the clinical status of patients who are either overweight or obese 

Target:
BMI ≤ 25
Men waist ≤ 94 cm
Women waist ≤ 80 cm
Monitor
Review 6 monthly

Patient to implement
GP to monitor
Dietician to advise and monitor

Physical Activity

Appropriate activity levels to optimise health

Awareness of the benefits of aerobic, and strength and balance training

Patient exercise routine incorporating strength / balance and aerobic training

The provision of advice and exercise therapy

Target: At least 30 minutes walking or equivalent 5 or more days per week

Patient to implement
GP to monitor 
Physiotherapist to advise and monitor

Smoking

Complete cessation

Smoking cessation strategy:
Consider:
- Quit
- Medication

Patient to manage
GP
Smoking cessation advisor

Alcohol

Appropriate safe levels of alcohol consumption

Your target:
≤ 2 standard drinks per day (men)
≤ 1 standard drinks per day (women)

Reduce alcohol intake
Patient education

Patient to manage
GP to advise / monitor

2. Biomedical | | |

Cholesterol / Lipids

Your target:
Cholesterol ≤ 4.0 mmols/L
Triglycerides ≤ 2.0 mmol/L
LDL-C ≤ 2.5 mmol/L
HDL-C ≥ 1.0 mmol/L

Annual check

GP

Blood pressure

Your target:
< 140/90

Check every 6 months

GP

3. Medication | | |

Medication review

Correct use of medications, minimise side effects 

Ensuring patient awareness and understanding of therapies used in the management of dermatitis: their indications, contra-indications and side effects.

Patient education
Review medications

GP and pharmacist to review and provide education

First line therapies

Moisturiser therapies 

Humectants attract transepidermal water to stratum corneum and retain it there
E.g.
Glycerin
Macrogols
Propylene glycol
Urea

Emollients smooth roughened surface of stratum corneum by filling in the spaces between dry skin flakes with oil droplets. Some emollients have an occlusive effect – reduction of transepidermal water loss

E.g.
Soft paraffin

Silicones - water resistant – used as barrier creams
E.g.
Dimeticone 

Formulations

Bath oils

Creams

Lotions

Ointments

Patient education 
Review medications

GP and pharmacist to review and provide education

Second line therapies

Topical steroids 
Mild steroids

Moderate steroids

Potent steroids

Patient education 
Review medications

GP and pharmacist to review and provide education

Gp to review at 6 monthly intervals or more frequently if indicated

Pharmacist to review opportunistically at each dispensing.

Pharmacist to refer back to prescribing clinician (or GP) as appropriate in the event of any issues arising.

Eradication of infection

Oral antibiotics
Oral acyclovir
Topical antibiotics (less recommended)

Patient education 
Review medications

GP / Specialist
Pharmacist

Pharmacist role in TCA

Pharmacist to be aware of underlying disease process which merits pharmacological intervention

Pharmacist to review the indications for therapy, assess the side effects of therapy and monitor compliance with therapy

GP and Pharmacy to reconcile prescribing and dispensing records

Pharmacist to monitor the progress of symptoms and or complications and provide appropriate advice to patient which may include advice to return to see the prescribing clinician and or general practitioner

4. Psychosocial | | |

Depression

Identify and manage depression associated with chronic diseases including chronic dermatitis

Assessment.
Medication or cognitive behaviour therapy

GP to assess and initiate management
Psychologist to provide talking therapies

Social isolation

Reduce social isolation

Improve social support 
Eg referral to support group

GP to advise and monitor

Copy of GP Management Plan offered to patient?  y

Copy / relevant parts of the GP Management Plan supplied to other providers?  y

GP Management Plan added to the patient’s records?  y

Date service was completed: | Proposed Review Date:

I have explained the steps and any costs involved, and the patient has agreed to proceed with the plan. YES