Expert opinion: dermatology in a secure environment

Prison life can exacerbate skin conditions and make treatment more challenging. By Dr Nigel Stollery

In the past few years, there has been radical reform in healthcare within the secure setting. Gone are the days of prison healthcare being the remit of doctors who could not find employment elsewhere; the aim now is for healthcare in prisons to be the same as everywhere else. Until April 2006, prison healthcare was managed and regulated by the Home Office; since then, all commissioning responsibility has become the remit of PCTs.

In general terms, prisoners' dermatological conditions are no different from those of the general public. Obviously, the age of the prison inmates will determine whether certain conditions are going to be seen. In a young offenders' institution, for example, basal cell carcinoma and squamous cell carcinoma will be rare, while in a lifers' prison, with an older, more established population, they will be more common.

Medication in prison
Access to OTC treatment and self-help is much reduced. In most prisons, there will be an in-house canteen list, from which certain items can be bought; this will invariably include shampoos, such as polytar, and emollients, such as aqueous cream. Prices are similar to those in the average supermarket, but with prisoners' wages being about £10 a week, the cost of such items is proportionately higher than for non-prisoners.

In many prisons, there will be a general 'not in possession' policy, where all medication is held by healthcare services and has to be collected daily. Where this is the case with, for example, antibiotics for acne, compliance may be affected because of the inconvenience of daily collections.

Inability to apply topical agents properly, either because of the location of the dermatosis (for example, the back and other difficult areas) or comorbid disabilities, such as osteoarthritis, means that without the help of family or friends, compliance may again be a problem.

Medications may be traded between prisoners for misuse, especially stronger opiate-based analgesics, such as co-codamol, tramadol and gabapentin, and antidepressants. These are taken as cocktails, sometimes after modification by mixing or heating and skimming. In many cases, prisoners are unaware of what they have taken, or when they took it. This makes diagnosing 'drug reactions' virtually impossible. Access to medical records from before a person's arrival in prison is not usually possible, so there is often no history of previous treatments.

General problems affecting skin health
Stress levels are often much higher in prisons, for obvious reasons. Long hours spent 'banged up' away from family and friends, parole meetings, bullying and conflict with other inmates are all common and may aggravate certain dermatoses, such as psoriasis and acne vulgaris.1 Flares in conditions such as eczema and psoriasis are common after entering prison. Stress may also mean that boredom results in more picking and scratching of dermatoses, such as eczema.

Prison cells are generally small and cramped, with windows that may not open and heating that is controlled centrally. Overheating is well known to increase the itch associated with skin problems, leading to more scratching and excoriations. In most prisons, showering is the norm, with no bathing facilities available. Showers are communal, increasing the risk of spread of verrucas and tinea pedis, but also limiting use of bath additives that are often helpful in the treatment of conditions such as eczema. Furthermore, washing of clothing and bedding is communal, with little choice over soap powders and additives that may present problems for some, and prison issue clothing may be coarse and uncomfortable - the opposite of what would normally be recommended.

Referral and outpatient care
There are currently about 80,000 prisoners (approximately 95 per cent male) in 143 jails in England and Wales, in four different categories, from A (maximum security) to D (low security/open prisons).

Some prisons have inpatient hospital facilities with 24-hour cover; others offer a GP-type service. Depending on the experience and interest of medical officers at the prison, some may have access to a GPSI in dermatology, who may offer minor surgery within the prison; in other cases, anything beyond basic GP dermatology may require referral to secondary care.

When secondary care services are required, including two-week wait services, a referral is made in the usual way, but for logistical reasons, many more outpatient appointments tend to be cancelled for prisoners than for the general public, because of security problems. Outpatient visits pose increased security risks, so if prison staff are not available, appointments have to be rescheduled, often at short notice.

Another problem can arise if a prisoner is transferred to another jail outside the area, just before an appointment. This means they have to be referred again, sending them to the bottom of the waiting list. Often, if the appointment is simply a follow-up, they may be lost and not seen again.

Dermatological problems in prison
Very few studies have examined dermatology in secure environments. One US study investigated dermatological problems from 1976 to 1983 and showed that the most common conditions were warts (18 per cent), eczema (11-13 per cent) and acne (14-19 per cent).2

Another study, at Doncaster Prison, revealed the most common dermatoses to be acne (38 per cent), eczema (30 per cent), fungal infections (15 per cent), psoriasis (10 per cent) and others (10 per cent),3 figures which correlate with my own experience (see box 1). Outside prison, many of these conditions could be managed with OTC preparations and no need for primary care intervention. However, in prison, this is not usually possible.

Problems seen at Gartree Prison over the past 12 months
  • Acne
  • Eczema
  • Tinea infections (including onychomycosis, tinea pedis and ringworm)
  • Warts and verrucas (including genital warts)
  • Impetigo and folliculitis
  • Dermatitis artefacta (including deliberate self-harm)
  • Psoriasis
  • Benign skin lesions (moles, skin tags, epidermoid cysts)
  • Leg ulcers
  • Keloid scars
  • Skin cancers (superficial and nodular basal cell carcinoma)

As a visiting GP looking after 572 prisoners, my time can be limited, so in Gartree Prison we operate a nurse triage system. In some cases, depending on the triage nurse's experience, this will avoid the need for a consultation. The most common nurse-managed problems include dry skin, mild eczema, dandruff, mild scalp psoriasis, tinea pedis, warts, verrucas and ringworm. This system works very well.

In other prisons, pharmacists play a valuable part, reducing the need for medical officer input. At Doncaster Prison, Rod Tucker set up a pharmacist-led dermatology clinic, which has been evaluated in a study.3 He concluded that a pharmacist can manage a range of common skin conditions using treatments currently available without prescription. His study showed that 90 per cent of prisoners were satisfied with the service, 85 per cent reported an improvement in their condition and 96 per cent reported that they had benefited by gaining a better understanding of their condition and its management.

Security and treatment
Security considerations are always of paramount importance in the prison setting and as such, some drugs and treatments are not used. In my experience, this is not so much of a concern with dermatological treatments. At Gartree Prison, we use a wide range of oral and topical treatments, as would be the case for the non-prisoner population.

For those with severe acne, oral isotretinoin is used, under the guidance of the local dermatologist, and for those who struggle to apply topical treatments, nurses can be called on to help, although many will allow other prisoners to help them.

Although showers are the norm at Gartree Prison, bathing facilities are available in the healthcare wing. There are only a small number of inpatient beds for those with particularly bad flares; these can be used for help with treatments. In general, we try to avoid hypnotics, but sedative antihistamines, such as hydroxyzine, can be used to aid sleep and nocturnal pruritus.

Healthcare in prisons has improved, but with increasing prisoner numbers, services continue to be stretched.

- Dr Nigel Stollery is a GPSI in dermatology and medical officer at Gartree Prison, Leicestershire

1. Kimyai-Asadi A, Usman A. The role of psychological stress in skin disease. J Cutan Med Surg 2001; 5: 140-5.
2. Brauner GJ, Goodheart HP. Dermatologic care behind bars. J Am Acad Dermatol 1989; 20: 707-8.
3. Tucker R. Exploring prisoners' view of a pharmacy-led dermatology clinic. Pharmacy in Practice 2004; 4: 113-14.

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