Rosacea Consultation

Patient Name

First

Last

SECTION 1

Preconsutation Assessment

.

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

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Inclusion Checklist

Patients from 18 years of age.
Patients suffering from mild to moderate rosacea, where erythema is the predominant symptom (erythematotelangiectatic rosacea) and there is no prominent telangiectasia.

Exclusion Checklist

Patient is immunosuppressed through disease, treatment or medication.
Patients for whom no valid consent has been received.
Hypersensitivity to the active substance(s) or to any of the excipients or trace residuals in Mirvaso® 3mg/g Gel. See section 2 and 6.1 of the relevant SPC
Known or suspected pregnancy.
Breast-feeding women.
Patients under 18 years of age.
Individuals with renal or hepatic impairment.
Patients receiving monoamine oxidase (MAO) inhibitor therapy (e.g. selegiline or moclobemide).
Patients on tricyclic (e.g. imipramine) or tetracyclic antidepressants which affect noradrenergic transmission (e.g. maprotiline, mianserin or mirtazapine).
Individuals with symptoms of keratitis (such as eye pain, blurred vision, or sensitivity to light).
Unclear diagnosis of rosacea.
Patients with severe rosacea.
Patients who are undergoing or who have recently undergone procedures (where the treated area of skin has rosacea), such as: ̵ Depilation ̵ Chemical hair treatments ̵ Chemical peels ̵ Dermabrasion ̵ Laser resurfacing the skin ̵ Phototherapy
Patients with sunburn should not use this product on affected skin until recovered.
Patients who: ̵ Have cerebral insufficiency. ̵ Have coronary insufficiency or severe cardiovascular disease. ̵ Have depression. ̵ Have postural hypotension. ̵ Have Raynaud’s syndrome. ̵ Have thromboangiitis obliterans

Tick the one that applies

Patient is INcluded in Treatment
Patient is EXcluded from 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

If other please specify

Caution refer to PGD if required

-Contact with the mouth, eyes, lips, mucous membranes and areas with abraded skin should be avoided

-severe irritation or contact allergy

-avoid application to irritated or damaged skin

-Gel should be discontinued temporarily if worsening of erythema or flushing occurs during treatment

-Exacerbation of rosacea symptoms

-Gel should be discontinued temporarily if worsening of erythema or flushing occurs during treatment.

-If the skin condition is assessed as causing significant social or psychological problems, it is recommended that the patient is referred to the appropriate specialist.

Product Interactions

Prior to supply and where indicated, medication that the patient is using should be checked for product interactions using the British National Formulary (BNF) and SPC. This includes checking that the patient’s medication does not suggest conditions that are excluded from treatment under this PGD.

• No interaction studies have been performed. Interactions with systemically administered medicinal products are considered minimal as the systemic absorption of fusidic acid is negligible

If patient on any medication, check product interactions

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Action if excluded

Discuss with patient and document the reasons for exclusion from treatment under the PGD.
• If the patient has consented, refer them to their GP and/or inform their GP.
• Signpost to other services if appropriate.
• Document the reasons for exclusion and any action taken, in the patient’s medication record.
• When treatment is postponed reschedule as appropriate.
• Reschedule or refer to General Practitioner, dermatologist or appropriate clinic as clinically indicated.
• Patients with symptoms of keratitis (such as eye pain, blurred vision, or sensitivity to light) should be urgently referred to an ophthalmologist

Action if patient
declines treatment

Ensure patient/carer fully understands the risks of declining the service.
• Advise the patient/carer about the benefits of the service.
• Refer patient to GP if appropriate.
• Document the reasons for declining the service and any action taken, including advice given to the patient.
• Reschedule treatment if appropriate.
• Explain NHS eligibility for this service where appropriate

Additional Consultation Notes

See PGD for dose, adverse reaction, advice and treatment

Healthcare Professional Name

First

Last

GPHC Number

Date

SECTION 1

Preconsutation Assessment

SECTION 2 – Complete this session during consultation

Caution refer to PGD if required

Product Interactions

Action if excluded

Action if patient
declines treatment

See PGD for dose, adverse reaction, advice and treatment

Start Assessment

Complete Patient Details

SECTION 1

Preconsutation Assessment

SECTION 2 – Complete this session during consultation

Caution refer to PGD if required

Product Interactions

Action if excluded

Action if patient declines treatment

See PGD for dose, adverse reaction, advice and treatment

Start Assessment

Complete Patient Details

Action if patient
declines treatment