Acne Consultation Form

Patient Name

First

Last

SECTION 1

Use completed patient assessment form to complete this session

Patient Consent

obtained from the patient/carer who does not want to consult with their GP and would prefer to access treatment from the PGD user

Layout

Inclusion Checklist (For Azelaic Acid)

Patients from 12-64 years of age
Patients suffering from mild to moderate inflammatory or non-flammatory acne vulgaris

Patient is either included in Azelaic or Treclin and not both.

Inclusion Checklist (For Treclin 30g gel)

Patients from 12 years of age
Patients with acne vulgaris where comedones, papules and pustules are present.

Patient is either included in Azelaic or Treclin and not both.

Tick the one that applies

Patient is INcluded for Azelaic Acid Treatment
Patient is INcluded for Treclin 30g gel Treatment

Exclusion Checklist (For Treclin 30g gel)

Exclusion Checklist (For Azelaic Acid)

Tick the one that applies

Patient is EXCLUDED for Azelaic Acid Treatment
Patient is EXCLUDED for Treclin 30g gel Treatment

SECTION 2 – Complete this session during consultation

Type of consultation

Video
Telephone
Walk In

Check patient ID presented e,g passport, Drivers License or Photocard

Passport
Drivers License
Photocard
Other

Other, please specify

Action if excluded (Azelaic Acid)

Discuss with patient and document the reasons for exclusion from treatment under the PGD
Record any advice given and actions/decisions in notes (written or electronic)
Reschedule or refer to General Practitioner or appropriate clinic as clinically indicated

Action if excluded (Treclin 30g)

Discuss with patient and document the reasons for exclusion from treatment under the PGD
Record any advice given and actions/decisions in notes (written or electronic)
Reschedule or refer to General Practitioner or appropriate clinic as clinically indicated
Patients who are temporarily excluded due to procedures or sunburn should be allowed to recover before treatment is initiated

List clinical features and document assessment

The clinical features of acne include: • Seborrhea or excess production of grease • Two types of lesion are described for acne vulgaris – • Non-inflammatory lesions – which include open comedones (blackheads) and closed comedones (whiteheads) • Inflammatory lesions – which include papules, pustules, nodules, and cysts

Document advice given when excluded

Further information that may be relevant

Read through caution and advise patient accordingly

Skinoren contains a small amount of benzoic acid, which is mildly irritating to the
skin, eyes and mucous membranes.• Skinoren also contains propylene glycol, which may cause skin irritation.

• Contact with the mouth, eyes, lips, mucous membranes and areas with abraded skin should be avoided. In case of accidental contact, the areas should be rinsed well with large amounts of water. If eye irritation persists, patients should consult a physician.
• Application to patients with eczematous or broken skin may lead to irritation, so
should be avoided.
• Worsening of asthma in patients treated with azelaic acid has been reported
rarely during post-marketing surveillance.
• If the patient experiences irritancy or dermatitis, reduce frequency of application
or temporarily interrupt treatment and resume once the irritation subsides.
Treatment should be discontinued if the irritation persists.
• Referral to the GP should be considered if acne is causing the patient significant
psychological distress, regardless of severity.

Name

First

Last

GPHC Number

Date

SECTION 1

Use completed patient assessment form to complete this session

SECTION 2 – Complete this session during consultation

Start Assessment

Complete Patient Details