Chronic hand/foot eczemas are common, but treatment is often challenging, with widespread dissatisfaction over current available options. Detailed history is important, particularly with regard to potential exposure to irritants and allergens. Patch testing should be regarded as a standard investigation. Individual treatment outcomes and targets, including systemic therapy, should be discussed early with patients, restoring function being the primary goal, with clearing the skin a secondary outcome. Each new treatment, where appropriate, should be considered additive or overlapping to any previous therapy. Management extends beyond mere pharmacological or physical treatment, and requires an encompassing approach including removal or avoidance of causative factors, behavioural changes and social support. To date, there is little evidence to guide sequences or combinations of therapies. Moderately symptomatic patients (e.g. DLQI ≥ 10) should be started on a potent/super‐potent topical corticosteroid applied once or twice per day for 4 weeks, with tapering to twice weekly application. If response is inadequate, consider phototherapy, and then a 12‐week trial of a retinoid (alitretinoin or acitretin). Second line systemic treatments include methotrexate, ciclosporin and azathioprine. For patients presenting with severe symptomatic disease (DLQI ≥ 15), consider predniso(lo)ne 0.5–1.0 mg/kg/day (or ciclosporin 3 – 5 mg/kg/day) for 4–6 weeks with tapering, and then treating as for moderate disease as above. In non‐responders, botulinum toxin and/or iontophoresis, if associated with hyperhidrosis, may sometimes help. Some patients only respond to long‐term systemic corticosteroids. The data on sequencing of newer agents, such as dupilumab or JAK inhibitors, are immature.

Background To investigate the aetiology of pigmented purpuric dermatoses (PPD). Methods 63 patients with a provisional diagnosis of PPD were assessed. Skin biopsies were performed to confirm the clinical diagnosis. Haemostasis was assessed using platelet function analyser-100 (PFA-100), light transmission aggregometry (LTA), impedance aggregometry (Multiplate) and measurement of clotting times and clotting factors. Chronic venous disease (CVD) was assessed by duplex ultrasound. When not contraindicated, patients were advised to discontinue haemostatic-modifying drugs or supplements for 4 weeks after which the laboratory measurements were repeated and the clinical resolution of PPD was assessed. Subsequently, a cohort of patients identified with CVD underwent endovenous interventions and further resolution of PPD was assessed. Results CVD was found in 48 patients (76.2%) while haemostatic abnormalities were found in 36 (57.1%). 30 patients (47.6%) had concurrent CVD and haemostatic abnormalities. Modifiable risk factors such as the intake of platelet inhibitors or other drugs and supplements such as fish oil were identified in 53 patients (84.1%). These could be ceased in 35 patients of whom 28 (80.0%) achieved either complete or partial resolution of PPD. Treatment of the underlying CVD was performed in 18 patients resulting in complete or partial resolution in 17 (94.4%). In seven patients (11.1%), no CVD or haemostatic abnormalities were identified, and the risk factors included dietary factors such as excessive caffeine or soft drink consumption. Conclusion Haemostatic abnormalities and CVD contribute to the pathogenesis of PPD. Resolution of PPD in the vast majority of patients may be achieved by cessation of modifiable risk factors and in particular platelet-modifying drugs or supplements and treatment of the underlying venous disease.

Background California State Board of Pharmacy passed Senate Bill 493 authorizing pharmacists to furnish self-administered hormonal contraceptives, nicotine replacement products, and naloxone. Although California Senate Bill 493 expanded pharmacists’ scope of practice, limited implementation persists. Objective The objectives of this study were to assess the implementation of pharmacists’ prescriptive authority to furnish hormonal contraceptives, naloxone, and NRT in California as allowed by the Board of Pharmacy and availability of these services to patients in order to facilitate the development of strategies to expand them. The objective of the first part was to investigate reported awareness and barriers to implementation of services, while the second part was to report actual implementation rates. Methods This was an IRB-approved two-part cross-sectional survey that explored factors that may be associated with the limited implementation of the expanded scope of practice services. Results The two-part study had a total of 389 respondents. In the first part of the study, there were a total of 84 respondents. The majority reported that they were aware that pharmacists have the authority to furnish hormonal contraceptives, naloxone, and NRT, but services were limited. In the second part of the study, there were a total of 305 respondents, each responding to questions addressing only one of the three services: hormonal contraceptives (104 respondents), naloxone (101 respondents), and NRT (100 respondents). Within those subgroups, 19% of the respondents stated they offer hormonal contraceptives, 10% offer NRT, and 84% offer naloxone. Conclusion The results of the two-part study suggested that pharmacists’ authority to furnish these services were limited, thus patients’ access to these services were also limited.