Recognising and managing skin conditions: triage in the pharmacy

Switzerland has one of the highest skin cancer rates in the world: around 3,500 people develop a malignant melanoma each year, an estimated 25,000 develop non-melanoma skin cancer, and about 300 people die of melanoma annually. According to the Federal Office of Public Health’s MonAM monitoring system, the age-standardised melanoma incidence has more than doubled since the 1980s — from 13 to 29 cases per 100,000 inhabitants (period 1983–1987 versus 2018–2022). [1,2] Among men, Switzerland has the highest melanoma incidence in Europe. Added to this is a specifically alpine reality: snow amplifies the effect of UV by up to 90 per cent, and according to the Swiss Cancer League around 40 per cent of men deliberately do not apply sunscreen. [3] In this context the pharmacy is not only the point of contact for the most common chronic skin diseases — atopic dermatitis, acne, rosacea, mycoses, psoriasis — but frequently also the first place where a suspicious skin change is mentioned at all. From this dual function follows the actual Swiss pharmacy mandate in dermatology in 2026: competent care and OTC counselling and triage — the ability to recognise what can be managed OTC, what requires a medical prescription and what belongs immediately in the dermatology clinic.

Clinical and epidemiological background: skin diseases in Swiss care

The state of skin health in Switzerland is shaped by two mutually reinforcing phenomena: high UV exposure through alpine leisure behaviour, and an ageing population in which cumulative light damage becomes clinically manifest. [1,3] The MonAM monitoring system documents, over the period from 1983–1987 to 2018–2022, a rise in age-standardised melanoma incidence from 13 to 29 cases per 100,000 inhabitants — a doubling in 35 years. [1] The Swiss Cancer League puts the annual number of new malignant melanoma diagnoses at around 3,500 and mortality at around 300 people, and estimates the annual incidence of non-melanoma skin cancer (basal cell and squamous cell carcinoma) at around 25,000 cases. [2,3]

The pharmacy’s role in dermatology has been growing in Switzerland for years, because it is structurally the lowest-threshold point of access for questions about the skin. A patient with a rash or an itchy plaque frequently asks in the pharmacy first — before the appointment with the family doctor or the dermatologist. The consequence: a large share of the counselling and sales effort of the Swiss pharmacy concerns skin applications — from basic care and sun protection to complex support of prescribed topicals.

The task of the pharmacy professional at the counter is rarely prescribing — it is usually triage. Four triage decisions are particularly frequent and particularly consequential in daily practice: (1) is pure skin care enough (emollients, cleansing products, sun protection)? (2) Is OTC treatment (e.g. hydrocortisone 0.5%, clotrimazole, bufexamac, salicylic acid, shale oil) sufficient and defensible? (3) Is a medical prescription needed — and is the family doctor or the dermatologist the right address? (4) Is there a red flag constellation that belongs in a prompt dermatology consultation (suspected malignancy, a severe acute course, a life-threatening allergy, severe pustulosis, perioral eczema with eye involvement, and so on)? The following sections discuss the most common clinical pictures with their concrete triage criteria and Swiss treatment options in 2026.

Atopic dermatitis: stepped therapy and the new biologics landscape

Atopic dermatitis (synonymously: atopic eczema, neurodermatitis) is a chronic inflammatory skin disease that runs in flares. Swiss and international estimates put the lifetime prevalence at 15–30 per cent in childhood and 2–10 per cent in adults. [4] The diagnosis is made clinically according to the Hanifin and Rajka criteria: at least three major criteria (itching, typical morphology and distribution, a chronically relapsing course, a personal or family history of atopy) plus at least three minor criteria (dry skin, palmar hyperlinearity, raised total IgE, cheilitis, the Dennie–Morgan fold, pityriasis alba and others).

The stepped therapy concept (per the EuroGuiDerm Living Update 2025 and the German AWMF S3 guideline, adapted for Switzerland): [4,5]

Step 1 – basic therapy for everyone. Daily use of emollients in sufficiently high doses (lipid content typically 10–20%, with or without urea/glycerol/ceramides). A consumption of a 200 g tube per week in adults is a realistic target; too low a consumption is a frequent indicator of adherence problems and an occasion for counselling.

Step 2 – topical anti-inflammatory therapy for mild to moderate disease. Topical glucocorticoids by class I–IV: class III/IV (e.g. mometasone furoate, methylprednisolone aceponate) for flares on the trunk and limbs; class I/II (e.g. hydrocortisone) for the face and intertriginous areas. Topical calcineurin inhibitors (tacrolimus 0.03%/0.1% (Protopic®), pimecrolimus 1% (Elidel®)) are a valuable steroid-free alternative for the face, eyelids and skin folds as well as for proactive maintenance therapy twice weekly at sites of predilection. Protopic® 0.03% is authorised in Switzerland from 2 years, Protopic® 0.1% only for adults; Elidel® from 2 years. Important: at the start of therapy a temporary local burning can occur, which subsides after 5–7 days — a frequent adherence breaker that should be mentioned in advance in pharmacy counselling.

Step 3 – systemic therapy in moderate to severe disease. Here the therapeutic landscape has changed fundamentally over the past 8 years. Whereas ciclosporin (Sandimmun® Neoral®, authorised in Switzerland from 16 years for severe atopic dermatitis, 2.5–5 mg/kg/day, treatment cycle max. 8 weeks), methotrexate or azathioprine (off-label) used to be the only options, targeted substances are available today: [4,5]

• Dupilumab (Dupixent®): a humanised anti-IL-4/IL-13 receptor antibody; first Swissmedic authorisation 5.4.2019 (authorisation no. 66649), and since October 2023 extended from the age of 6 months (one of the most broadly authorised biologicals in paediatric dermatology; basis: the LIBERTY AD PRESCHOOL study). Initial dose and fortnightly maintenance dose subcutaneously. Swiss Specialities List limitatio: IGA 4 or SCORAD > 50 or EASI ≥ 21.1; prior consultation of the medical adviser; prior insufficient response to topical therapy plus phototherapy (where available) plus a conventional immunosuppressant for at least one month, or contraindications. A common adverse effect: conjunctivitis (incidence depending on study and setting 10–30% in clinical practice, in randomised comparative studies in part only 1.7%; early counter-measures with artificial tears recommended). Additional effect on type 2 comorbidities (asthma from 6 years, chronic rhinosinusitis with nasal polyps from 18 years, prurigo nodularis authorised in Switzerland since 2024, eosinophilic oesophagitis).
• Tralokinumab (Adtralza®): a human anti-IL-13 antibody; authorised in Switzerland from 18 years. ECZTRA-3 study: EASI-75 in 56% of patients after 16 weeks. With a good response the injection interval can be extended to 4 weeks.
• Lebrikizumab (Ebglyss®): a human anti-IL-13 antibody that binds IL-13 selectively with high affinity. Authorised by Swissmedic on 30.08.2024 for moderate to severe atopic dermatitis in adults and adolescents from 12 years with a body weight ≥ 40 kg who are candidates for systemic therapy. Dosage: two initial doses of 500 mg (each 2 × 250 mg subcutaneously) in weeks 0 and 2, then 250 mg every 2 weeks until week 16, then a maintenance dose of 250 mg every 4 weeks (in some patients 250 mg every 8 weeks is sufficient). Common adverse effects: conjunctivitis, eye redness and itching, injection site reaction, dry eyes. Cost approval by the health insurer after consulting the medical adviser is required. [5,16]
• JAK inhibitors (oral) – baricitinib (Olumiant®), upadacitinib (Rinvoq®), abrocitinib (Cibinqo®): all authorised in Switzerland from 18 years. Advantage: rapid onset of effect (1–2 weeks). Safety notes: an FDA black box warning for cardiovascular events, thromboses and malignant disease; weigh the risks before prescribing — above all in patients over 65, smokers, and those with a cardiovascular or tumour history. Laboratory checks before and during therapy are required.
• Further substances in development or in the authorisation procedure will continue to widen the range of options in the coming years.

Topical JAK inhibitors and new substance classes. Topical ruxolitinib (Opzelura® 1.5% cream) was authorised by Swissmedic on 30.01.2025, but only for the treatment of non-segmental vitiligo with facial involvement in adults and adolescents from 12 years (on the Specialities List since June 2025). The US indication «atopic dermatitis» is not authorised in Switzerland. Delgocitinib (Anzupgo® 20 mg/g cream) was authorised by Swissmedic on 13.11.2024 for moderate to severe chronic hand eczema in adults (added to the Specialities List on 1.3.2025). Tapinarof (Vtama®, an AhR modulator) and topical roflumilast (Zoryve®) are authorised in the US for psoriasis and atopic dermatitis, but as at May 2026 not in Switzerland; oral roflumilast (Daxas®) has been authorised in Switzerland since 2011 for severe COPD — a different indication and dosage form. [5,17,18]

The pharmacy’s role in atopic dermatitis. Focal points: (a) adherence coaching on basic care (enough emollient, the right quantity, the fingertip rule: a class III topical steroid for two flat adult palms corresponds to roughly one fingertip unit); (b) advice on the correct use of topical steroids (flare therapy once daily for 7–14 days, then an attempt to stop); (c) support with proactive maintenance therapy using calcineurin inhibitors; (d) with patients on biologicals: practical support (injection technique, storage, addressing symptoms such as conjunctivitis early). Triage to dermatology is indicated with: a severe course despite adequate topical therapy, suspected superinfection (impetiginised, eczema herpeticum with grouped vesicles, acute deterioration), severe impairment of quality of life, a suspected differential diagnosis (psoriasis, scabies, allergic contact eczema).

Acne: fixed combinations, trifarotene and the Swiss isotretinoin standard

Acne vulgaris is the most common chronic skin disease among adolescents and young adults in Switzerland. Current estimates assume around 600,000 people affected in Switzerland, of whom 70–95 per cent of adolescents at least temporarily. [6] Pathophysiologically, acne rests on an interplay of hyperseborrhoea, follicular hyperkeratosis, colonisation with Cutibacterium acnes and an inflammatory reaction. Clinically three degrees of severity are distinguished: mild comedonal acne, moderate papulopustular acne and severe nodular or conglobate acne. Adult acne (acne tarda, above all in women aged 25 and over) is a distinct clinical picture, frequently with a hormonal component, often with premenstrual flares and a perimandibular or chin location.

The treatment algorithm (per the 2024 European S3 guideline and Swiss practice recommendations with the participation of the LUKS chief physician Feldmeyer): [6,7,8]

Mild comedonal acne: topical retinoids as monotherapy — adapalene 0.1%/0.3% (3rd generation, well tolerated, first line), tretinoin 0.025–0.05%, or trifarotene 0.005% (Aklief®, 4th generation, authorised by Swissmedic on 16.12.2020 for moderate acne vulgaris of the face and/or trunk in patients from 12 years, where more than half the surface is affected; binds selectively to the retinoic acid receptor γ; also effective in truncal acne and reduces the risk of atrophic scars). [7] An alternative where retinoids are not tolerated: azelaic acid 15–20% or benzoyl peroxide 2.5–5%.

Moderate papulopustular acne: here the topical fixed combination is the standard. The 2024 European S3 guideline gives a strong recommendation for the fixed combinations adapalene + benzoyl peroxide (e.g. Epiduo®, Epiduo® Forte) or clindamycin + benzoyl peroxide; the formerly frequently used fixed combination of clindamycin + tretinoin was downgraded to a medium recommendation. [8] Benzoyl peroxide is the central partner here — it reduces the risk of resistance with antibiotic components and is an effective antimicrobial agent. Important in pharmacy counselling: benzoyl peroxide bleaches textiles, so apply in the evening and wash off well in the morning, and choose light bedlinen and T-shirts.

Severe acne: systemic therapy. First choice in moderate to severe inflammatory forms: oral doxycycline (in combination with topical benzoyl peroxide or adapalene + benzoyl peroxide, not with a topical antibiotic alone, to avoid resistance), for a maximum of 3 months. In severe nodular or conglobate acne, treatment failure or a tendency to scarring: oral isotretinoin (Swiss brand names: Roaccutan®, Isotretinoin-Mepha®, Curacné® and others) — the gold standard since 1982. The Swiss Compendium standard for patients over 12 years: initially 0.5 mg/kg/day in 1–2 doses, maintenance dose 0.5–1.0 (max. 2) mg/kg/day, treatment duration 16–24 weeks, cumulative target dose 120 mg/kg; a possible second cycle at the earliest 8 weeks after the end of therapy. [6,19] Caution: isotretinoin is strictly teratogenic. Under the Swissmedic pregnancy prevention programme the following applies to women of childbearing potential: two methods of contraception from one month before until at least one month after the end of therapy, monthly pregnancy tests, information with a patient form requiring a signature, and a monthly prescription requirement. Pharmacists in Switzerland are required to dispense isotretinoin only against a monthly prescription and with the pregnancy prevention documents.

Hormonal treatment options in women: combined oral contraceptives with an antiandrogenic component (ethinylestradiol plus cyproterone acetate or chlormadinone acetate or dienogest or drospirenone); off-label spironolactone 50–200 mg/day in acne tarda. [6]

Clascoterone (Winlevi®), a topical androgen receptor antagonist and thus the first hormonally active topical agent for acne in decades, has been authorised in the US since 2024 and is in the authorisation procedure in the EU — in Switzerland, as at 2026, no application has been submitted. [6]

The pharmacy’s role in acne. The most frequent tasks: (a) OTC cleansing and mild topicals for comedonal forms with benzoyl peroxide contents of 2.5–5%; (b) adherence coaching with prescribed topicals (a typical cause of discontinuation is the initial skin irritation in the first 2–4 weeks, which can be cushioned with a reduced frequency of application and consistent care and sun protection); (c) support of patients on isotretinoin with lip care, eye drops, sun protection, regular reminders about the pregnancy prevention plan and attention to depressive symptoms; (d) triage to dermatology in nodular acne, scarring, severe acne tarda with a hormonal link, treatment-refractory courses, or where patients are psychologically affected.

Rosacea: the 2022 S2k guideline and the SGDV co-authored treatment cascade

Rosacea is a chronic inflammatory disease of the facial skin in adults, typically centrofacially located (cheeks, nose, forehead, chin). It is frequently misdiagnosed — as acne, as sunburn, as seborrhoeic dermatitis — and is among the most frequent occasions for counselling adults in the Swiss pharmacy. The updated S2k guideline of the German, professional and ophthalmological societies together with the SGDV (2022; AWMF register no. 013-065) is the Swiss reference; the SGDV is a co-author. [9]

Subtypes / phenotypes (today mostly understood not as subtypes but as phenotypes occurring simultaneously): [9]

• Erythematous rosacea: persistent centrofacial erythema with or without telangiectasia.
• Papulopustular rosacea: inflammatory papules and pustules, frequently in addition to the erythema.
• Phymatous rosacea: connective tissue hyperplasia, most frequently located on the nose (rhinophyma).
• Ocular rosacea: blepharitis, conjunctivitis, keratitis — often independent of the skin involvement.

Trigger factors: UV radiation, heat, spicy food, alcohol, stress, certain cosmetics. Identifying and avoiding triggers is part of any serious counselling.

The treatment algorithm (2022 S2k guideline): [9]

Mild to moderate papulopustular rosacea — topical first line (100% expert consensus): metronidazole 0.75%/1% (cream or gel), azelaic acid 15% gel, or ivermectin 1% cream (Soolantra®) — authorised in Switzerland by Swissmedic for adults (from 18 years) for the treatment of inflammatory lesions in moderate to severe papulopustular rosacea, once daily a pea-sized amount on forehead, chin, nose and both cheeks over 3 months. Ivermectin acts antiparasitically on Demodex mites (up to six times more numerous in rosacea) and is additionally anti-inflammatory.

Persistent erythema (erythematous rosacea): brimonidine 0.33% gel (Mirvaso®) once daily in the morning; onset of effect after 30 minutes, maximum 3–6 hours, duration of effect 8–10 hours. Caution: in 9% of patients flushing worsens, in 6.5% the erythema worsens — inform patients of this in advance. Alternative: oxymetazoline 1% cream (off-label use possible in Switzerland, authorised for rosacea in the US).

Severe or treatment-resistant papulopustular rosacea: low-dose doxycycline 40 mg/day (modified release) — the sub-antibiotic dose acts anti-inflammatorily without appreciable selection pressure on bacterial resistance. Alternative: low-dose isotretinoin 0.1–0.3 mg/kg body weight/day (off-label in Switzerland).

Phymatous rosacea: surgical, dermabrasive or laser treatment in dermatological hands.

Ocular rosacea: lid margin hygiene, where appropriate ciclosporin A eye drops 0.05%, short-cycle azithromycin (off-label), topical ivermectin or metronidazole periocularly (the latter for a maximum of 4–6 weeks because of periocular neurotoxicity).

The pharmacy’s role in rosacea. Focal points: (a) sun protection with a high SPF (≥30, ideally 50+) as the basic strategy; (b) care with mild, fragrance-free cleansing products and low-lipid creams (creams that are too rich intensify pustule formation); (c) trigger identification; (d) triage to dermatology in the phymatous form, a severe course, ocular involvement with eye irritation, or a suspected alternative diagnosis (perioral dermatitis in young women, lupoid rosacea with granulomatous papules, lupus erythematosus).

Dermatomycoses: tinea pedis, onychomycosis, pityriasis versicolor

Dermatomycoses are among the most common presenting diagnoses in the Swiss pharmacy. Three clinically relevant groups are to be distinguished: dermatophytoses (tinea corporis, tinea pedis, tinea cruris, tinea capitis, onychomycosis), yeast infections (candidal intertrigo, thrush) and pityriasis versicolor (caused by Malassezia furfur). The two most frequent occasions for counselling are tinea pedis and onychomycosis.

Tinea pedis is epidemiologically particularly relevant, because untreated it acts as a portal of entry conferring an increased risk of erysipelas. Tinea pedis — particularly the interdigital form — is an independent risk factor for erysipelas of the legs established in numerous studies: the original case-control study by Dupuy and colleagues (BMJ 1999) showed a strong association of toe web intertrigo with an odds ratio of 13.9; subsequent studies report odds ratios, depending on region, study design and form (interdigital versus plantar), in the range of about 2 to 14 — a clinically important argument for consistent treatment, particularly in older and diabetic patients as well as in recurrent erysipelas. [13]

The treatment algorithm: [13,14]

Interdigital and non-hyperkeratotic tinea pedis (mild moccasin type): a topical antifungal for 2–4 weeks. Options: terbinafine 1% cream/spray/gel (once daily, the shortest treatment duration thanks to the depot effect in the stratum corneum), bifonazole 1% cream (once daily), clotrimazole 1% cream (twice daily), miconazole, ciclopirox. In Switzerland most topical antifungals are available OTC — a clear indication for pharmacy counselling.

Hyperkeratotic plantar tinea pedis (pronounced moccasin type): systemic therapy with terbinafine 250 mg/day orally for 2 weeks (prescription-only in Switzerland). Alternative: itraconazole 200 mg/day orally for 4 weeks.

Onychomycosis (tinea unguium): here the diagnosis is medical, ideally with mycological identification of the pathogen (KOH preparation, culture, where appropriate PCR). The intensity of therapy depends on involvement of the nail matrix:

• Distal-lateral form without matrix involvement, less than 50% of the nail surface: topical treatment with amorolfine nail lacquer 5% (Loceryl® or the generics Amorolfin-Mepha, Amorolfin-Leman) once or twice weekly (the standard Compendium application), treatment duration 6 months for fingernails and 9–12 months for toenails; or a ciclopirox-containing nail lacquer (daily). Atraumatic nail abrasion with 40% urea ointment is an important first step. Loceryl® is on list B in Switzerland with an increased co-payment (40%) on the Specialities List.
• Matrix involvement or more than 50% of the nail surface affected: oral systemic therapy, as a rule terbinafine 250 mg/day for 6 weeks (fingernails) or 12 weeks (toenails); itraconazole pulse therapy at 2 × 400 mg/day for one week per month over 2–3 pulses is possible. Before starting: a check of liver enzymes.

Pityriasis versicolor: topical ketoconazole shampoo (2%), selenium disulfide shampoo, or ciclopirox-containing preparations as first line over 2–4 weeks. With recurrence or extensive involvement, systemic itraconazole 200 mg/day for one week. Important in counselling: the light patches (the hypopigmented variant) frequently disappear only after weeks to months even after successful eradication, once the skin has tanned evenly again — otherwise the impression of treatment failure arises.

Candidal intertrigo (groin, submammary area, abdominal folds): a topical antifungal with a low-potency steroid for short-term anti-inflammatory effect (e.g. miconazole plus hydrocortisone), keeping the area dry, skin care.

The pharmacy’s role in dermatomycoses. Focal points: (a) correct establishment of the indication — not every rash on the foot is a mycosis; differential diagnoses are erythrasma (red-brown patches, coral-red under Wood’s light, treatable with topical antibiotics), dyshidrotic eczema, pustular psoriasis, plantar hyperkeratosis; (b) advice on consistent use for the full duration of treatment (a frequent adherence gap when symptoms improve after a week); (c) hygiene measures (washing socks at 60°, disinfecting or rotating shoes, screening the family); (d) triage to the family doctor or dermatologist: onychomycosis with matrix involvement, hyperkeratotic tinea pedis, extensive tinea corporis, tinea capitis in children (always medical), people with diabetes with any form of foot mycosis, immunosuppressed patients.

Psoriasis: topical fixed combinations and systemic options

Psoriasis vulgaris has a prevalence of around 2–3 per cent in Switzerland. It frequently first manifests in young adulthood and shows a genetic component (HLA-Cw6). The clinical classification comprises the common plaque psoriasis (90%), guttate psoriasis (often after streptococcal tonsillitis), pustular psoriasis (localised or generalised), psoriatic arthritis (10–30% of those with skin involvement), and inverse psoriasis (intertriginous). [15]

The treatment algorithm (adapted for Switzerland from European and German guidelines): [15]

Mild psoriasis (body surface area < 10%, no psychosocial or functional pressure): topical therapy. First line: the fixed combination of calcipotriol plus betamethasone dipropionate (available in Switzerland as Daivobet® ointment/gel, Enstilar® foam spray, as well as Wynzora® cream and generics — the Compendium standard is 50 µg calcipotriol plus 0.5 mg betamethasone dipropionate per g, from 18 years, max. 15 g/day, max. 100 g/week, max. 30% of the body surface, flare therapy 4 weeks, then proactive therapy twice weekly); vitamin D analogues as monotherapy (calcipotriol, calcitriol, tacalcitol); topical glucocorticoids class III–IV; salicylic acid 5–10% for keratolysis before anti-inflammatory therapy; dithranol as a proven but time-consuming classic option.

Moderate to severe psoriasis (body surface area ≥ 10% or PASI ≥ 10 or DLQI ≥ 10): systemic therapy. Classic substances (available in Switzerland for decades): methotrexate 7.5–25 mg/week, ciclosporin (Sandimmun® Neoral®, from 16 years for severe psoriasis at 2.5–5 mg/kg/day), acitretin (Neotigason®), fumaric acid esters (Fumaderm®). Biologicals and small molecules authorised in Switzerland for plaque psoriasis: TNF-α inhibitors (adalimumab, etanercept, infliximab, certolizumab), IL-17 inhibitors (secukinumab, ixekizumab, brodalumab, bimekizumab/Bimzelx®), IL-23 inhibitors (guselkumab, risankizumab, tildrakizumab), the IL-12/23 inhibitor (ustekinumab), the oral PDE-4 inhibitor apremilast (Otezla®) (authorised in Switzerland for moderate to severe plaque psoriasis after failure of another systemic therapy and for active psoriatic arthritis), and the oral TYK2-selective JAK inhibitor deucravacitinib (Sotyktu®).

Tapinarof (Vtama®, an AhR modulator, authorised in the US for psoriasis since 2022 and for atopic dermatitis since 2024) and topical roflumilast (Zoryve®, a PDE-4 inhibitor, authorised in the US for plaque psoriasis from 6 years, seborrhoeic dermatitis from 9 years and atopic dermatitis from 6 years) are, as at May 2026, not authorised in Switzerland. Important for the distinction: oral roflumilast (Daxas®) has been authorised by Swissmedic since 2011 for severe COPD — that is a different dosage form and indication. [4,15]

The pharmacy’s role in psoriasis. Focal points: (a) care of the often also atopic skin with urea-containing or lipid-rich emollients; (b) adherence coaching with the fixed combination of calcipotriol plus betamethasone dipropionate (once daily, max. 100 g/week, flare therapy 4–8 weeks, then proactive therapy twice weekly); (c) attention to the comorbidities (psoriatic arthritis — early triage to rheumatology/dermatology is important; metabolic syndrome, cardiovascular disease, depression — involve the family doctor); (d) support of patients on biologicals (injection technique, protection against infection, regular tuberculosis screening checks).

Actinic keratoses, skin cancer and the ABCDE rule as a pharmacy standard

Actinic keratoses are UV-induced intraepithelial carcinomas in situ (squamous cell carcinoma in situ of the actinic keratosis type), which can progress to an invasive form. The rate of progression of a single actinic keratosis to an invasive squamous cell carcinoma varies widely in the medical literature — published estimates range from 0.1% to 10% per individual lesion over several years; where there are more than 10 actinic keratoses or field cancerisation, the overall risk of developing an invasive squamous cell carcinoma within 10 years is put at about 6–10% (Hommel 2016/2017). [10] They are particularly common in Switzerland because of high UV exposure, alpine leisure behaviour and demographic ageing. Clinically they appear as rough, scaly lesions, often more palpable than visible, on chronically light-exposed areas (bald scalp, forehead, temples, cheeks, ears, lips, backs of the hands, forearms, and the lower legs in women). Classification by Olsen (grades I–III) is standard — but is increasingly discussed critically in the updated guideline, since it provides no prognostic information about progression to an invasive squamous cell carcinoma.

Treatment options (the S3 guideline «Actinic keratosis and cutaneous squamous cell carcinoma», updated 2023): [10,12]

Cryotherapy with liquid nitrogen (–196 °C): first choice for individual lesions; quick to perform, cost-effective, with a low burden on patients. Healing in 60–80% of individual lesions. In Switzerland a service provided in dermatological and family practices.

Topical field therapy for multiple lesions or field cancerisation (several actinic keratoses on the same sun-damaged area of skin): [10,11,12]

• Tirbanibulin 1% ointment (Klisyri®) — authorised by Swissmedic since 2022 for field therapy of non-hyperkeratotic, non-hypertrophic actinic keratoses (Olsen grade I) of the face or scalp in adults. The treatment regimen: only five consecutive days once daily, treatment area up to 25 cm² (in the EU/Switzerland; in the US extended to 100 cm² since June 2024). Assessment of success after 8 weeks. Adverse effects: local skin reactions (erythema, scaling, crusting), as a rule mild. Mechanism: a microtubule inhibitor with Src tyrosine kinase modulation; apoptosis-inducing. Prix Galien Suisse, category «Cancer», 2025. [10,11]
• 5-fluorouracil 4% cream (Tolak® 40 mg/g): treatment duration 4 weeks, once daily; better local tolerability than 5-FU 5% cream. 5-FU 5% cream (Efudix®): twice daily over 2–4 weeks, until the erosion stage is reached; a pronounced local inflammatory reaction is integral to the therapy and a sign of its effect. Healing rates in a randomised study (Jansen et al., NEJM 2019): 5-FU had the highest effectiveness in multiple actinic keratoses. Also authorised for superficial basal cell carcinomas (off-label use where histologically confirmed).
• Imiquimod 5% cream (Aldara®, authorised in Switzerland, Compendium 80675): for non-hyperkeratotic, non-hypertrophic actinic keratoses of the face or scalp in adults, three times a week for 16 weeks, contact time about 8 hours. A Toll-like receptor agonist, immunomodulatory. A pronounced local inflammation. Also authorised for external genital warts and multiple superficial basal cell carcinomas (< 2 cm) on the trunk, neck and limbs. [12]
• Diclofenac 3% in hyaluronic acid gel (Solaraze®): a longer treatment duration (60–90 days twice daily), a favourable adverse effect profile, lower healing rates than 5-FU.
• Photodynamic therapy with aminolaevulinic acid or methyl aminolaevulinate, in dermatological hands. Very good with extensive involvement and in cosmetically sensitive locations.
• Ingenol mebutate (Picato®): withdrawn from the market in Switzerland in 2020 because of a suspected increased risk of tumour initiation with its use. [11]

Squamous cell carcinoma and basal cell carcinoma: medical diagnosis and treatment. Treatment options: excision (the standard), Mohs surgery (in cosmetically delicate locations such as the face, periocular, perinasal), curettage, radiotherapy, topical therapy in superficial basal cell carcinomas (imiquimod, 5-FU), and in the advanced or metastatic situation oral hedgehog inhibitors — vismodegib (Erivedge®) 150 mg/day and sonidegib (Odomzo®) 200 mg/day, authorised in Switzerland by Swissmedic for advanced basal cell carcinoma where surgery or radiotherapy is not possible (adults; on the Specialities List with a limitatio, with prior cost approval) or the immune checkpoint inhibitor cemiplimab (Libtayo®) in cutaneous advanced squamous cell carcinoma and in locally advanced or metastatic basal cell carcinoma after failure of or intolerance to a hedgehog inhibitor.

Malignant melanoma: the ABCDE rule as a pharmacy standard. [3] Every pharmacist and pharmacy professional in Switzerland should be able to apply the ABCDE rule confidently — as a low-threshold triage instrument: Asymmetry, Border (irregular, notched), Colour (several colours, dark black, red, blue-grey, white), Diameter (> 6 mm, though smaller ones can also be malignant), Evolution (change in shape, colour, size, new itching, bleeding). Important: the most frequent pointer from the patient is the «ugly duckling» — the naevus that looks different from all the others.

The pharmacy’s role in actinic keratoses and early detection of skin cancer. Focal points: (a) sun protection advice — a sufficient quantity (2 mg/cm² corresponds for an adult’s whole body to about 30 ml = a shot glass), repetition every 2 hours, and again after swimming or sweating; (b) Suva recommendations for outdoor workers; (c) ABCDE triage of skin changes shown to you; (d) early sensitisation of high-risk patients (fair skin types I–II, multiple naevi, family history, immunosuppression, outdoor occupation, previous skin cancer); (e) gegen-hautkrebs.ch as a Swiss patient resource. Triage to dermatology: any skin lesion with an ABCDE abnormality, non-healing wounds beyond 4 weeks, new nodular or hyperkeratotic lesions in older patients, a change in an existing naevus, unclear scaling lesions on sun-exposed skin.

What is frequently asked at the counter — with concrete triage examples

Four typical counselling situations in the Swiss pharmacy — with concrete triage decisions:

1. A young mother with a 4-year-old child and chronic eczema

The mother, around 30 years old, comes with her 4-year-old daughter, who has had chronic eczema in the elbow and knee flexures for months. The paediatrician has prescribed a class III steroid cream. The mother is uncertain: «I don’t want to rub cortisone into my child every day.» — Open question: «What concerns you most about the cortisone treatment?» Reflective listening: «Above all you don’t want your daughter to be harmed by the treatment — that is a good, responsible concern.» Professional classification: in atopic dermatitis the flare therapy model is established: apply the topical steroid consistently once daily for 7–14 days during the flare, then taper off — not chronic daily use. Class III is appropriate to age for the trunk and limbs in a 4-year-old child. For the face and intertriginous areas, class I/II or a calcineurin inhibitor (tacrolimus 0.03%, authorised from 2 years) would be the right choice. [4] Skin atrophy does not occur with proper flare use. Practical tip: the fingertip rule (a pea-sized amount of cream is enough for an area of two adult palms). Sufficient basic care with lipid-rich emollients between flares — at least 250 g a month in a small child. Triage to paediatrics or dermatology where the course is severe, eczema herpeticum is suspected, or growth or sleep is impaired.

2. A 17-year-old with moderate acne and treatment frustration

A 17-year-old patient comes with a prescription for the adapalene 0.1%/benzoyl peroxide 2.5% fixed combination (Epiduo®). After three weeks he is frustrated: «It’s getting worse, not better. My skin is red and burning.» — Open question: «What was your plan when you started the treatment?» Affirmation: «It is an important observation that your skin is reacting — and you have stuck with it, which is not a given.» Professional classification: the initial deterioration («acne flare», typically in weeks 2–4 with irritation, peeling and possibly delayed pustules) is a known, normal course with retinoid-containing therapy. A frequent breaking point for adherence. [6,7] A practical strategy: temporarily reduce the frequency of application to every other day; flank it with non-comedogenic, soothing care (e.g. a ceramide-containing emollient in the morning, sun protection SPF 50+ after 30 minutes); benzoyl peroxide bleaches textiles, so apply only in the evening; consistent lip and eyelid margin care. Conveying realistic expectations: onset of effect after 6–8 weeks, marked reduction after 12 weeks. Triage: with nodular acne, a tendency to scarring, severe acne tarda or psychological impairment, consider referral to dermatology for possible systemic therapy (doxycycline, isotretinoin).

3. A 55-year-old woman with persistent facial redness

A 55-year-old patient comes with persistent centrofacial redness («I think I have couperose. My husband says I always look as if I’d been drinking»), occasional pustules, and burning when applying her usual care cream. — Open question: «When is the redness strongest — and are there situations in which it improves?» Reflective listening: «It is not only the appearance of your skin that troubles you, but also what others read into it — that is a significant aspect.» Professional classification: probable rosacea, mixed form (erythematous and papulopustular). Triggers are frequently: heat, spicy food, alcohol, UV radiation, stress, certain cosmetics. [9] Steps: (a) recommend mild, fragrance-free cleansing and non-comedogenic, low-lipid care; (b) sun protection SPF 50+ as the basic strategy; (c) a trigger diary over two weeks; (d) triage to dermatology for the prescription of topical metronidazole/azelaic acid/ivermectin; (e) explanation: rosacea is not acne and often responds to different treatments, and classic OTC acne products can make it worse. With ocular involvement (burning, a gritty sensation, swelling of the lid margin): triage to the ophthalmologist and dermatologist together.

4. A 70-year-old mountain guide with «dry patches» on his bald scalp

A 70-year-old pensioner, formerly a mountain guide in the Bernese Oberland, comes for routine care against dryness. In passing he shows the pharmacist a rough, slightly scaly, 8 mm, pale-red patch on his bald scalp: «I’ve had this for a few months, it feels rough, sometimes it bleeds when I scratch it. A nurse said it was dryness.» — Open question: «Has the patch changed recently?» Patient: «Maybe a bit bigger. And a crust keeps forming.» Triage decision: this constellation is a clear indication for a prompt dermatology consultation (suspected actinic keratosis, possible differential diagnosis of squamous cell or basal cell carcinoma). The patient has all the risk factors: high lifetime UV exposure (a mountain guide), the location on the bald scalp, age, a course beyond 4 weeks, a tendency to bleed. [10,12] Practical communication: «It is very probably not dangerous, but we should be sure. A rough patch like that, which does not resolve by itself, should be looked at once by a dermatologist — they can create clarity in five minutes, with a small sample if necessary. Would you like me to help you arrange an appointment?» Context for patient education: actinic keratoses can today be treated with a 5-day therapy (tirbanibulin/Klisyri®, authorised by Swissmedic since 2022) — the threshold to diagnosis is low in medicinal terms. [11]

Swiss care and tariff reality: OTC, prescription, Specialities List

The Swiss care landscape in dermatology is characterised by a clear division of tasks — with the pharmacy at the low-threshold interface.

The OTC area (self-medication and pharmacist prescribing under LOA V): sun protection, emollients, basic care; hydrocortisone 0.5% OTC; topical antifungals (bifonazole, clotrimazole, terbinafine cream/spray); topical antiseptics (octenidine, chlorhexidine, povidone-iodine); salicylic acid, shale oil, mild keratolytic preparations; certain topicals dispensed without prescription within pharmacists’ competence. This is where the pharmacy’s main counselling responsibility lies.

The prescription-only area (list B, as a rule through the family doctor or dermatologist): topical glucocorticoids from class II; topical calcineurin inhibitors (tacrolimus, pimecrolimus); topical antibiotics and their fixed combinations (clindamycin + benzoyl peroxide, adapalene + benzoyl peroxide); topical ivermectin/metronidazole/azelaic acid gel at prescription strength; brimonidine gel; tirbanibulin ointment; 5-FU creams; imiquimod; oral antifungals; oral doxycycline; methotrexate; acitretin; ciclosporin; isotretinoin (with the Swissmedic pregnancy prevention programme); oral apremilast; oral deucravacitinib; oral JAK inhibitors.

Specialities List status with a limitatio (specialist prescription) applies to most modern biologicals and JAK inhibitors: dupilumab, tralokinumab, baricitinib, upadacitinib, abrocitinib in atopic dermatitis; all TNF-α, IL-17 and IL-23 inhibitors in psoriasis. These substances are as a rule prescribed through the dermatology clinic or practice, with documented moderate to severe disease and, where applicable, an insufficient response to conventional therapy. The pharmacy has an important supporting function here: storage (frequently a cold chain), injection training, adherence monitoring, addressing adverse effects (conjunctivitis with dupilumab, skin redness, infections under JAK inhibitors).

Early detection of skin cancer and pharmacy pilot projects: the SGDV conducts an annual national skin cancer awareness campaign together with the Cancer League (gegen-hautkrebs.ch). Individual Swiss pharmacy chains run pilot projects on low-threshold skin cancer triage in cooperation with dermatologists (e.g. a teledermatology consultation from the pharmacy). The health insurance act revision of 21.3.2025 brought pharmacies newly reimbursable services in the areas of vaccination, medication review and HPV/colorectal cancer screening — skin cancer screening is not part of this revision. Suva publishes recommendations for outdoor workers: sunscreen with SPF ≥ 30 in sufficient quantity, a hat, protective clothing, breaks in the shade. [3]

Safety, adherence and pharmacy practice with topicals and systemic therapies

Topical glucocorticoids: the most important safety rules in pharmacy counselling: (a) the correct class for the location — class I/II for the face and skin folds, class III–IV for the body and limbs. (b) Flare therapy daily for a maximum of 2–4 weeks, then an attempt to stop or proactive therapy twice weekly. (c) Avoid continuous use beyond 3 months (a risk of skin atrophy, perioral dermatitis with facial use, tachyphylaxis). (d) Infants and small children: only low-potency topical steroids, short treatment cycles, small areas. [4]

Topical calcineurin inhibitors (tacrolimus, pimecrolimus): an initial burning sensation in the first 5–7 days (a frequent adherence breaker — explain in advance). The FDA black box warning about tumour risk with long-term use: real-world data over the past 20 years have not confirmed an increased lymphoma risk; use is safe, but sun protection is recommended. [4]

Topical retinoids: pronounced photosensitivity — sun protection with SPF ≥ 30, ideally 50+, is obligatory. Pregnancy: oral isotretinoin is strictly contraindicated (teratogenicity); topical retinoids are likewise contraindicated in pregnancy or to be used with caution (Swiss practice: discontinue during pregnancy). [6]

Isotretinoin (oral): strict pregnancy prevention (two methods of contraception, monthly pregnancy tests, renewal of the medical prescription every month). Common adverse effects: cheilitis (lip care is part of the therapy), xerosis, dry eyes, photosensitivity, muscle and joint pain, rising transaminases, rising triglycerides. From the pharmacy side: sensitivity to depressive changes in mood, which can occur in rare cases under isotretinoin — encourage patients to inform the medical practice. [6]

Topical antibiotics (clindamycin, erythromycin): only in combination with benzoyl peroxide, never as monotherapy — a resistance risk. [6,8]

Brimonidine 0.33% gel: in 9% of patients flushing worsens, in 6.5% the erythema worsens — explain in advance. Application once daily in the morning. [9]

Tirbanibulin / 5-FU / imiquimod (actinic keratosis topicals): the local inflammatory reaction is integral to the therapy. Patients can expect pronounced erythema, scaling and crusting — this is a sign of the effect. Explaining the picture to be expected prevents discontinuation. [10,11,12]

Oral terbinafine: a check of liver enzymes before starting and where treatment lasts beyond 6 weeks is recommended. Very rare hepatotoxicity. Taste disturbances in 3–8% of those treated. [13,14]

Dupilumab and other biologicals: common adverse effects: conjunctivitis (dupilumab 15–20%), injection site reactions, herpes reactivation. Before starting therapy, tuberculosis screening and hepatitis B/C status. Live vaccines are contraindicated during biological therapy. [4,5]

Oral JAK inhibitors: the FDA black box warning for cardiovascular events, thromboses and malignant disease (particularly in patients over 65, smokers, those with a cardiovascular or tumour history). Regular laboratory checks (haematology, lipids, liver enzymes, creatine kinase). [4,5]

Practice tool: triage table for the counter

Outlook 2026/2027

Dermatology is on the move in several directions in 2026, and the Swiss pharmacy is directly involved in several of these movements.

First: an extension of the topical armamentarium. Topical ruxolitinib (Opzelura® 1.5% cream) has been authorised in Switzerland since 30.01.2025 for non-segmental vitiligo with facial involvement (adults and adolescents from 12 years) — the first topical JAK inhibitor with a Swiss authorisation in this indication. [17] Lebrikizumab (Ebglyss®) has been authorised since 30.08.2024 for atopic dermatitis from 12 years (≥40 kg). [16] Delgocitinib (Anzupgo® 20 mg/g) has been authorised since 13.11.2024 for chronic hand eczema, and was added to the Specialities List on 1.3.2025. [18] Tapinarof (Vtama®) and topical roflumilast (Zoryve®) are authorised in the US for psoriasis (tapinarof) and for plaque psoriasis, atopic dermatitis and seborrhoeic dermatitis (roflumilast) respectively, but as at May 2026 not yet in Switzerland. Clascoterone (Winlevi®), the first topical androgen receptor antagonist against acne, has been authorised in the US since 2020 and is in the authorisation procedure in the EU — in Switzerland, as at 2026, no application has yet been submitted. [6] These substances will probably enter Swiss first-line therapy over the coming years in competition with the classic topical steroids and retinoids. The pharmacy will provide both explanatory work and adherence coaching here.

Second: an expanding biologics landscape. In atopic dermatitis, psoriasis and, more recently, chronic spontaneous urticaria, hidradenitis suppurativa and prurigo nodularis, further anti-interleukin antibodies and JAK inhibitors are entering Swiss care. The pharmacy’s role is shifting increasingly from acute OTC counselling to continuous adherence and safety support. The limitatio requirements of the Specialities List demand documented courses — the pharmacy can make a clinical contribution here with standardised medication reviews and patient training, which from 1.1.2027 will also be remunerated thanks to the health insurance act revision.

Third: early detection of skin cancer as a pharmacy competence. The SGDV/Cancer League campaign gegen-hautkrebs.ch is an established Swiss brand; individual pharmacy chains are experimenting with teledermatology triage and skin check campaigns. While the health insurance act revision of 2025/2027 did not introduce skin cancer screening as a reimbursed service (unlike HPV and colorectal cancer screening), the Swiss pharmacy is positioning itself prospectively as a triage interface for a population-wide secondary prevention offering. The combination of pharmaceutical competence, a low threshold and visibility among the population is a structurally strong argument here. [2,3]

Fourth: the Swiss alpine reality as an occasion for counselling. With demographic ageing, the frequency of actinic keratoses, non-melanoma skin cancer and melanomas will continue to rise. UV exposure in the Swiss mountains is clinically relevant: snow amplifies the effect of UV by up to 90 per cent, and at 2,000 m the UV burden in summer is about 20 per cent higher than at sea level. The pharmacy is the natural place for ongoing, individualised sun protection advice — and for the annual recommendation of skin self-examination according to the ABCDE rule.