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[post_date] => 2025-12-17 16:21:38
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[post_content] => Case scenario
Fernando, a 16-year-old student, walks into your pharmacy concerned about a rough, painful lesion on the bottom of his foot. He informs you that he has been picking at it, as it has been bothering him, to the point that he is now limping and avoiding sports (football and swimming). He has not tried any treatments, but he has ‘Googled’ it.
On examination, you notice a thickened and tender lesion with black dots on the surface. He is not taking any regular medicines and is otherwise healthy.
Learning objectivesAfter reading this article, pharmacists should be able to:
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A cutaneous wart is a common, viral skin growth caused by the human papillomavirus (HPV). They are typically classified based on their location on the body and their structure.1 Warts are generally classified as1,2:
Most warts are harmless. Without active treatment, warts will disappear on their own within months to years.1,2 Occasionally, warts can cause discomfort, cosmetic concern or cause temporary functional impairment (e.g. plantar warts).2 Once active treatment is started, persistence is key to ensuring optimal eradication.2
Cutaneous warts are common, particularly among children, adolescents, and individuals who are immunocompromised. Globally, the prevalence of cutaneous warts varies between 7% and 12% in the general population, with the highest rates reported among school-aged children (10–20%).3
In Australia, the most frequently observed types of cutaneous warts are common warts (verruca vulgaris) on hands and knees, and plantar warts (verruca plantaris) on the soles of the feet.2 Studies have found that approximately one-quarter (24%) of school children have had at least one wart, with a significantly higher prevalence observed among those who swim regularly or share footwear.4
Warts are caused by infection with specific types of HPV, of which more than 200 genotypes have been identified.3 Of those, types 1, 2, 4, 27 and 57 are most commonly associated with cutaneous warts.1,3 HPV is transmitted via direct contact with infected skin or indirectly through contaminated environments (e.g. communal showers, swimming pool decks, or gym mats).1–3 HPV can survive for days on surfaces, facilitating indirect spread.6
Once HPV breaches the skin barrier, it infects basal keratinocytes within the epidermis. The virus then induces proliferation of keratinocytes without inducing cell lysis or triggering a significant immune response, thereby evading immune detection.6 As infected cells differentiate and migrate toward the skin surface, viral replication continues, giving rise to the following characteristic histopathological changes that produce the rough, raised appearance of warts5:
Since viral activity remains confined to the epidermis and does not invade deeper tissues, the lesions are typically benign.6
Several factors influence susceptibility to cutaneous warts.
Age
Cutaneous warts are frequently observed in children and adolescents.1 Prevalence tends to decline in adulthood.7
Skin trauma
Cuts, abrasions or frequent friction facilitate viral entry by disrupting the skin barrier, thereby increasing susceptibility.1,2
Immunosuppression
Individuals who are immunocompromised (e.g. those with HIV infection), recipients of organ transplants, or patients receiving immunosuppressive therapy are more prone to persistent and treatment-resistant warts.1
Occupational or recreational exposure
Certain individuals are placed at increased risk due to their environment, such as butchers (susceptible to abrasions, cuts), swimmers (prolonged exposure to moist, communal environments) and athletes (increased skin to skin transmission in contact sports and shared equipment). Overall risk is generally increased with close contact and communal environments, although evidence varies among studies.3
Poor skin hygiene and occlusion
Excess moisture and skin maceration compromise the integrity of the epidermis, creating favourable conditions for infection. 2,3
Atopic dermatitis
A compromised skin barrier may increase susceptibility.1,5
Warts typically have the following presentation5:
Warts range in size from a few millimetres to over a centimetre in diameter and characteristically disrupt normal skin lines.5 They may occur as solitary lesions or in clusters, sometimes coalescing into plaques, particularly in immunocompromised individuals.8
Table 1 summarises the distinguishing features that differentiates subtypes.
Symptoms
Most cutaneous warts are asymptomatic, but they may cause pain, itching or tenderness, especially when located on pressure points like the feet or periungual areas.5,6 Cosmetic distress and social embarrassment are common, particularly for visible or facial warts.8
Diagnosis
Cutaneous warts are diagnosed clinically, based on their appearance, location and patient history.1,3,8 Several skin conditions may resemble the appearance of cutaneous warts5,8:
A thorough patient history, lesion inspection, and understanding of risk factors can aid in distinguishing benign warts from conditions that may require further investigation or treatment.3
Prognosis
The prognosis for cutaneous warts is generally favourable, with most cases being self-limiting. Spontaneous resolution occurs in 50–70% of cases within 2 years, particularly in children and adolescents.4,5
The likelihood of resolution depends on several factors, including patient age, immune status and lesion characteristics.8 Younger patients typically experience higher clearance rates, while those who are immunocompromised may develop more extensive and persistent disease.1 Warts located on plantar or periungual sites, as well as larger lesions, tend to be more resistant to resolution.6
Even without treatment, the immune system can eventually clear the virus.2 However, recurrence is possible, and reinfection may occur via autoinoculation (self-spread from one site on the body to another) or contact with contaminated surfaces.2
The primary aim of treatment for cutaneous warts is to stimulate a host immune response against HPV, often by inducing irritation or inflammation within the lesion.10 By doing so, the following can be achieved3,6,10:
Importantly, patients should be educated that no treatment guarantees 100% success, and that multiple treatment sessions and sustained compliance may be required. Notably, one-third of warts resolve spontaneously within 3 months and two–thirds resolve in 2 years.5,9
Management should be individualised, considering the patient’s age, immune status, wart type, number, location, duration and impact on quality of life.5
Monitoring
In children or patients with recent-onset warts that are not painful or distressing, simply waiting and monitoring is a reasonable option.5,8 This approach may be preferred in young children where treatments may cause discomfort.
Salicylic acid
Salicylic acid (SA) at a concentration of 15–40% is considered the first-line pharmacological treatment for most cutaneous warts.5,9 As a keratolytic agent, it works by softening and progressively removing hyperkeratotic tissue.9 Treatment involves daily application, often for up to 12 weeks.9,10 Evidence indicates that efficacy of SA is improved when the wart is soaked in warm water for 5–10 minutes followed by mechanical debridement, such as paring or filing the lesion prior to application, as this improves penetration of SA into affected tissue.2,10
SA preparations available in community pharmacy include solutions, paints, sticks and pens that are applied daily,9 and medicated discs that are typically left on for 48 hours and repeated for up to 12 weeks as required.7,8
Evidence for the use of SA as a first-line option has shown a cure rate of up to 75% when compared to placebo.9
Adverse effects such as local irritation, blistering or pain are common following SA application.2 Covering the wart with occlusive tape after applying SA helps to prevent contact with healthy skin.10
Salicylic acid with lactic acid and podophyllum resin
Lactic acid is a keratolytic agent that softens and breaks down the thickened skin of warts, helping them shed more easily. It is often combined with SA in topical treatments to enhance removal and promote healthy skin regeneration.10
Podophyllum resin is available in some OTC products and is typically combined with salicylic and lactic acids to treat stubborn common warts. Its active compound, podophyllotoxin, arrests cell division and destroys wart tissue.2,8 Because systemic absorption can cause toxicity, products are applied sparingly to intact skin and avoided in pregnancy or on large or inflamed areas. 2,9 Higher-strength podophyllotoxin for anogenital warts is Schedule 4 (Prescription Only).2
Cryotherapy
Cryotherapy is a second-line option for adults or older children with painful, persistent, or cosmetically concerning warts.9 Cryotherapy with liquid nitrogen (through a medical practitioner) or dimethyl ether and propane (DMEP), a non-prescription product, induces tissue necrosis through freezing.8,9 Non-prescription DMEP products are colder than ambient but do not reach liquid nitrogen temperatures and are typically less effective.10
Cryotherapy is usually administered at intervals of 2–3 weeks for up to 12 weeks, with multiple sessions often required for optimal clearance.9 The procedure can be painful, so its use is typically avoided in young children.9
Adverse effects include pain, blistering and pigmentation changes. Its efficacy is comparable to SA when compliance to therapy is high.3,9
Alternative or specialist treatment
In cases where first- and second-line therapy fails, patients may be referred for specialist treatments. Options include immunotherapy (e.g. topical imiquimod), intralesional antigen injections, as well as procedural approaches, such as laser therapy or electrosurgery.3,8,9
Imiquimod stimulates local immune responses and may be used off-label for cutaneous warts, particularly recalcitrant (resistant to treatment) or widespread cases.5,8,9 While evidence is limited for non-genital warts, it remains an option for referral or specialist use.9
Laser therapy, curettage and surgical excision are typically reserved for warts not responding to conservative measures.3 These options carry risks such as scarring and are performed in specialist settings.2,9
Referral should be considered for immunocompromised patients, for lesions with features suggestive of skin cancer, in cases of extensive or treatment-resistant warts, and bleeding or rapidly growing lesions.9
Other therapies
Occlusion – duct tape
Occlusion with duct tape is a low-cost method that involves covering the wart with duct tape and changing it weekly with periodic debridement.9 Although evidence is mixed,9 it is a well-tolerated adjunct or alternative in paediatric cases, or for patients preferring non-chemical options.8 Patient expectations should be modest.9
Zinc
Oral and topical zinc have been studied in wart treatment due to their immunomodulatory properties.9 Oral zinc has been shown to be effective at treating recalcitrant warts when administered at therapeutic doses.8 However, evidence is limited, and results across studies have been mixed. 8 Its role in routine management remains uncertain.9
Treatment considerations
Treatment of cutaneous warts requires persistence.3 Many patients may discontinue therapy prematurely, often due to perceived lack of efficacy, highlighting the importance of counselling around expected treatment duration.1-3
Adverse effects such as local irritation, blistering, or pain are common.1 Inappropriately applied SA or cryotherapy can damage surrounding skin, spread the virus or lead to secondary infection.10 The use of petroleum jelly around the lesion or tape over the lesion is recommended to protect surrounding healthy skin.10
Other skin conditions can mimic the presentation of cutaneous warts, thereby requiring alternative management. Lesions that bleed, ulcerate or change in appearance should also prompt further assessment.
Precautions
Children, people with diabetes and those who are immunocompromised may present as more complicated cases or have contraindications to standard therapy.8,9 Avoid the use of keratolytic agents and aggressive debridement in patients with diabetes or peripheral vascular disease, as acute inflammation and ulceration may occur.2 Plantar warts in people with diabetes require cautious management, as neuropathy and impaired circulation increase the risk of ulceration, secondary infection and delayed wound healing.6 Alternative treatments or referral to a GP or dermatologist may be required.
Children are more sensitive to irritation and systemic absorption of active ingredient, therefore keratolytic agents should be used with caution. However, SA can be used in children with careful application and skin protection, avoiding large areas or irritated skin.2
Complications
Secondary infection
Warts that are irritated by scratching, shaving or treatment can become infected. The need for good hygiene practices and protecting the lesion site is important.6 Educate patients about signs of infection, such as4–6:
Patients should be advised to withhold treatment and refer to a GP if signs of infection are present.
Pain and irritation
Plantar warts may become painful due to pressure while walking.6 The use of keratolytics and cryotherapy can result in additional pain.
To prevent discontinuation of treatment, cushioning for plantar warts (e.g. with felt pads) may be recommended to alleviate discomfort,6 or advise patients on appropriate analgesia if needed.
Overuse or misapplication of topical treatments can cause irritant contact dermatitis or chemical burns. Precise application and protective measures can minimise irritation.10 Treatments for warts can potentially lead to scarring.10
Spread and recurrence
Immunosuppression8 and local trauma, especially when adjacent healthy skin is accidentally pared prior to application of keratolytic treatments, can increase the risk of spread to adjacent areas. Recurrence is common and does not necessarily indicate treatment failure.1,6,10
Follow-up
Warts commonly require up to 12 weeks of therapy to achieve clinical resolution, especially with non-prescription treatments.2 Without structured follow-up, patients may discontinue treatment prematurely due to slow response, leading to treatment failure or recurrence.
Pharmacists play an important role in the early identification, treatment, education and monitoring of cutaneous warts. By taking a thorough history when patients present with skin concerns, pharmacists can assist with timely intervention, reducing transmission and preventing complications.1
Pharmacists may recommend first-line therapies such as SA and guide patients on correct use to optimise outcomes and minimise adverse effects.
Pharmacists can also provide education and counselling on the viral nature of warts, transmission routes and treatment expectations.
Importantly, pharmacists are positioned to encourage patients to return for follow-up if progress is sub-optimal, allowing ongoing monitoring of adherence, response or the need to refer.1,2,10
Pharmacists must be able to recognise red flags, such as non-resolving lesions, sensitive anatomical locations or immunocompromised status, and refer to GPs for further management.8
An important part of counselling involves explaining the likelihood of wart recurrence and emphasising the role of good hygiene in reducing the risk of infection.1,2,10
Conclusion
Cutaneous warts are common and generally have a favourable prognosis, with many resolving spontaneously within months to years. However, people often seek treatment to improve cosmetic appearance or reduce discomfort.2 Warts may persist, recur or become susceptible to secondary infection if inappropriately treated.1,2,10
Pharmacists play an active role in treatment by identifying warts, advising on treatment, counselling on correct application, and identifying when referral may be required.
Case scenario continuedYou explain to Fernando that the lesion is consistent with a plantar wart and recommend starting a combination salicylic acid and lactic acid preparation with nightly application following debridement. You counsel on application technique, the importance of good hygiene and remaining consistent with treatment. You encourage him to return in 2 weeks for review, and when he presents, you find it is noticeably reduced and no longer painful. You advise him to continue with treatment until it disappears, but not for longer than 12 weeks, and to remain vigilant for signs of infection or recurrence. Fernando is grateful for your help and soon returns to participating in sports. |
Diyar Emadi MBA, BPharm, CredPharm (MMR), CDE, CPT, SCOPE certified, MPS is a credentialed pharmacist and diabetes educator with expertise in insulin pumps, obesity and weight management. Founder of Synergy Medicine Consulting, he works as a consultant pharmacist in general practice and as a diabetes educator alongside endocrinologists in specialist practice. With an MBA and a background spanning community, hospital and pharmaceutical industry roles, Diyar brings clinical and strategic insight to his work as a medical writer.
Sharon Ambalal MPH, BPharm, MPS
[post_title] => Cutaneous warts in community practice [post_excerpt] => Pharmacists play an important role in the early identification, treatment, education and monitoring of cutaneous warts. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => cutaneous-warts-in-community-practice [to_ping] => [pinged] => [post_modified] => 2025-12-17 17:00:00 [post_modified_gmt] => 2025-12-17 06:00:00 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=30883 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Cutaneous warts in community practice [title] => Cutaneous warts in community practice [href] => https://www.australianpharmacist.com.au/cutaneous-warts-in-community-practice/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 31108 [authorType] => )
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[post_content] => The most-read stories of the year highlight where clinical practice, regulation and professional reform collided.
From sweeping Therapeutic Guidelines updates to unresolved scheduling decisions and award wage reform, these five stories captured pharmacists’ attention and reflected the pressures shaping practice in 2025.
1. Therapeutic Guidelines overhaul UTI treatment
The Therapeutic Guidelines on antibiotics underwent the biggest update in TG history, encompassing 1,400 medicine recommendations to reflect new evidence and rising antimicrobial resistance.
The first stage targeted infections managed in primary care, with one of the most significant shifts made to the management of urinary tract infections (UTIs). Trimethoprim is no longer first-line therapy for uncomplicated cystitis in non-pregnant adults due to resistance in Escherichia coli (E. coli). Instead, nitrofurantoin is now recommended as the preferred first-line option, with fosfomycin and cefalexin listed as alternatives.
This update impacted pharmacists offering UTI treatment services nationwide, particularly in states such as New South Wales – where trimethoprim was previously first-line therapy.
2. Is Rikodeine still being rescheduled?
Last year, the TGA made an interim decision to upschedule dihydrocodeine due to concerns about potential misuse, abuse and dependence. The TGA Delegate’s interim decision was to amend the Pharmacist Only entry for dihydrocodeine to restrict undivided oral liquid preparations to a maximum primary pack size of 100 mL from 1 October 2025.
But the final decision is yet to be published, with a public consultation process causing the delay. In September 2024, the TGA confirmed that final decisions had been deferred while the consultation responses were further considered.
In the meantime, dihydrocodeine scheduling remains unchanged – with pharmacists continuing to field frequent requests for Rikodeine, often from patients without symptoms of dry cough.
3. Hiprex becomes a Pharmacist Only medicine
Methenamine hippurate, sold as Hiprex and Uramet, officially became a Pharmacist Only medicine on 1 October 2025. Previously unscheduled and available as a general sales medicine, the aim of the change was to ensure pharmacist oversight and safer use.
While a Pharmacy Only designation was considered, the TGA concluded this would not prevent inappropriate use among people who have not been medically assessed.
4. What you need to know about the paracetamol regulation changes
From 1 February 2025, paracetamol pack sizes sold in pharmacies changed as part of the TGA’s final decision on paracetamol access controls. Packs containing 50–100 tablets or capsules became Pharmacist Only medicines and general-sale pack sizes reduced from 20 to 16 tablets, among other changes – with the aim of reducing the amount of paracetamol stored in households to prevent harm from intentional overdose.
Each year, around 225 Australians are hospitalised with liver injury due to paracetamol overdose, with the highest rates among adolescents and young adults, particularly females.
Pharmacists should act as ‘champions for the change’, reinforcing safe use and helping to limit surplus paracetamol in homes, said PSA Senior Pharmacist – Strategic Policy, Peter Guthrey MPS at the time.
‘The data on intentional overdose involving paracetamol is alarming … scheduling changes are not the full solution, but are a strategy which could make a positive difference if it changes the patterns of paracetamol supply,’ he said.
5. Fair Work publishes gender undervaluation decision on pharmacist award
In April, the Fair Work Commission’s Expert Panel for pay equity in the care and community sector issued its initial decision on the Gender-based undervaluation – priority awards review, making significant determinations for the Pharmacy Industry Award 2020, under which most community pharmacists are employed.
The Expert Panel found that pharmacists covered by the award have been subject to gender-based undervaluation, with the assessment considering factors such as:
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[post_content] => New year, new policy and practice changes. Here’s what pharmacists will need to navigate from January.
In 2026, pharmacists can expect some changes to education, medicine costs and credentialing standards.
AP has rounded up the key changes pharmacists can expect from 1 January.
1. PBS co‑payment will drop
From 1 January 2026, the maximum Pharmaceutical Benefits Scheme (PBS) co‑payment for general patients will drop from $31.60 to $25.00 per prescription.
This marks a major reduction in out-of-pocket costs for Australians without a concession card, and the first time in more than 20 years that PBS medicines will cost no more than $25.
However, indexation on the general patient co-payment will resume in 2027 in line with the Consumer Price Index (CPI). Although PBS medicines will not be permanently capped at $25, the long‑term trajectory of general patient co‑payments will rise from a much lower baseline.
2. Transition to the new MMR credential must be completed
By 1 January 2026, pharmacists must have transitioned to the APC’s new Medication Management Review credential to continue:
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[post_content] => The Pharmaceutical Society of Australia (PSA) recently launched the PSA Standards for Continuing Professional Development (CPD) for Pharmacists, marking a new era for the accreditation of CPD activities for the pharmacy profession.
The launch of the PSA Standards follows the retirement of the Australian Pharmacy Council (APC) Accreditation Standards for CPD Activities on 31 December 2025. Developed through extensive consultation with the profession, the PSA Standards provide a contemporary framework to guide the quality and educational integrity of continuing professional development activities for pharmacists.
With the commencement of these Standards, CPD providers can apply for accreditation under the PSA Accredited CPD framework.
All supporting materials, including application forms and the PSA Accredited CPD Provider Handbook, will be available on the PSA website from 5 January 2026.
PSA acknowledges and thanks the individuals and organisations who contributed feedback during the consultation process and looks forward to supporting providers in delivering high-quality education for pharmacists.
PSA National President Associate Professor Fei Sim FPS reflected on the process of developing the Standards, acknowledging the work of all involved, including the individuals and organisations who provided feedback during the consultation period.
“The approval of the PSA standards for CPD for pharmacists marks a significant milestone in PSA’s already rich history in upholding quality education standards, now spanning decades,” she said.
“We know our education and continuing professional development are core values for our members. I want to assure you that these standards will give pharmacists the confidence that the CPD they access is of high quality.
“I sincerely thank everyone who participated in the consultation process. It is an incredible achievement to be sharing this news only 5 months after announcing PSA’s intent to publish these education standards.”
To view the Standards or enquire about the accreditation process, please visit https://www.psa.org.au/cpd/
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[post_content] => From early detection to screening and medicine management – pharmacists are increasingly involved in reducing the burden of kidney disease.
Chronic kidney disease (CKD) is a common but often ‘silent’ condition. One in three Australians are at risk of developing progressive CKD resulting from comorbidities such as hypertension, diabetes and cardiovascular disease. And most people are asymptomatic until significant kidney damage has occurred.
Familiarity with patients’ medical history equips pharmacists to act as first identifiers of potential CKD and to suggest Kidney Health Checks – which can find CKD in time to better manage the condition. People with diabetes, hypertension, family history of kidney disease, or those who are over 18 and from an Aboriginal and Torres Strait Islander family should have annual Kidney Health Checks. Current smokers and people with other risk factors, such as cardiovascular disease or obesity, should have Kidney Health Checks every 2 years.
Screening for CKD
A trial of CKD screening by pharmacists is currently underway across Australia, covering nearly 1,500 patients in 192 community pharmacies.
According to the University of Sydney’s Associate Professor Ron Castelino, a practising renal pharmacist at Blacktown Hospital, the trial was inspired by the discrepancy between the routine kidney function test results available to hospital pharmacists – who can then adjust doses of medicines cleared by the kidneys – and the lack of information available to community pharmacists.
The pilot first required pharmacists to assess patients’ likelihood of developing CKD using a series of questions about their risk factors. Around 30% of the patients in the recruitment pool were assessed as having a moderate to severe risk of developing CKD within 5 years. They were offered a point-of-care kidney function test, which is essentially a finger-prick test similar to the glucometer test used to manage diabetes, A/Prof Castelino says.
The point-of-care test provides an immediate reading of the patient’s estimated glomerular filtration rate (eGFR) and levels of serum creatinine to measure how well the kidneys are filtering waste from the blood. Patients identified as having impaired kidney function are referred to their general practitioner (GP) for more comprehensive blood and urine tests, spaced over at least 3 months, to diagnose CKD, he adds.
‘There are two or three benefits that I see straight away with the point-of-care device screening, particularly in rural and remote areas where pharmacy is more accessible,’ A/Prof Castelino says.
‘Patients can walk in and get the finger-prick test as the initial screening. Those who do come up with a decline in kidney function can be referred to the doctor straightaway, so that’s a massive positive. It’s also a good opportunity for pharmacists to see whether the dosage of medicines cleared by the kidneys may need to be adjusted.’
Management in pharmacy
Pharmacists’ therapeutic knowledge puts them in a unique position to help people manage CKD. A recent systematic review and meta-analysis of randomised controlled trials – including adults with a diagnosis of CKD and those with and without kidney replacement therapy – found pharmacist interventions resulted in statistically significant improvements
in systolic blood pressure and haemoglobin levels.5
But the findings showed pharmacist interventions had mixed results for various outcomes, according to the scientists. ‘Future studies should be more robustly designed and take into consideration the role of the pharmacist in prescribing and deprescribing, the findings of which will help inform research and clinical practice,’ they concluded.5
Kidney care for Aboriginal and Torres Strait Islander peoples
Chronic kidney disease is prevalent among Aboriginal and Torres Strait Islander peoples.6 Breonny Robson, Kidney Health Australia’s General Manager, Clinical and Research, says pharmacists should familiarise themselves with the Caring for Australians and New Zealanders with Kidney Impairment (CARI) recommendations for providing culturally safe kidney care in Aboriginal and Torres Strait Islander peoples.7
‘Pharmacists should also ensure pharmacy staff undertake formal cultural safety training and establish that they have referral pathways for First Nations peoples back to their local Aboriginal Community Controlled Health Organisations (ACCHOs) and GP to ensure continuity of care,’ she says.
‘First Nations peoples should be encouraged to have their annual 715 health check [the Medicare number for a comprehensive health check], ensure that they are correctly identified as Aboriginal and/or Torres Strait Islander at the service and that they are correctly enrolled in the Closing the Gap program.’8
Ms Robson adds that pharmacists should discuss potential point-of-care testing and in-pharmacy screening with the local ACCHO, so that community members are linked to their regular health service for continuity of care.
Pharmacists supporting CKD treatment
CKD usually entails ‘super-polypharmacy’.9 With patients often managing 16–20 medicines, pharmacists have a vital role to play in medicines review, dose adjustment and transplant support.
Hanh Tran, Senior Pharmacist (Renal) at Royal Adelaide Hospital, says polypharmacy is a significant challenge in CKD due to patients’ unstable renal function, their frequent medicines changes, and the involvement of multiple specialists (including endocrinologists, cardiologists and GPs).
‘Patients often experience “pill burden” and contradictory advice,’ she says. ‘A classic example is calcium: commonly prescribed as a phosphate binder in CKD, it must be taken with food to bind dietary phosphate – which is contrary to the usual advice for calcium supplementation.’
Renal dosing principles include maintaining medicine records, providing patients with updated lists of medicines, and ensuring they are equipped to manage complex medicines regimens.
Ms Tran says that dosing advice should be provided to relevant healthcare providers, including doctors, nurses and nurse practitioners.
Meanwhile, people living with CKD in rural and regional areas may have limited access to nephrology services or dialysis centres.10 Gauri Godbole FPS, a specialist aged care pharmacist at Gosford Hospital, says that in cases of patients with advanced CKD requiring polypharmacy, it’s important to ‘prioritise medicines with clear evidence of benefit that are aligned to patient goals, and ensure renal-appropriate dosing’.
Identifying the patient’s best possible medication history, including the over-the-counter and herbal products they take, is the first step, she says. Ms Godbole then identifies the high-risk or nephrotoxic medicines and recommends dose adjustments or, in certain cases, discontinuation, based on renal function and clinical benefit.
‘Goals of care often evolve over time, serving as an important catalyst for deprescribing,’ she says.
‘We identify nephrotoxic, duplicate or low-value medicines for deprescribing, especially where benefits are limited in advanced illness. Tools such as STOPP/START, STOPPFrail and STOPPCog, alongside multidisciplinary input and shared decision-making, support tailored recommendations. Deprescribing should be monitored with regular follow-up, symptom checks, and tapering if needed.’
The Australian Pharmaceutical Formulary and Handbook (APF) supports the concept of deprescribing in patients with progressive CKD where the benefit of long-term preventive medicines (such as statins in the elderly) may no longer outweigh the risks. Deprescribing should also be considered for medicines with narrow therapeutic windows or renal toxicity such as lithium, NSAIDs, metformin and SGLT2 inhibitors (depending on eGFR).11
The APF recommends assessing kidney function before adjusting dosages and referencing renal dosing guides when determining dose changes. It also recommends avoiding or reducing the dosage of nephrotoxic drugs such as NSAIDs and aminoglycosides, and advises special caution with drugs cleared renally – including metformin (which carries a risk of lactic acidosis), digoxin and DOACs (such as apixaban).11
Providing transplant support
Community pharmacists can provide essential support for kidney transplant recipients in regional, rural and remote areas of Australia.12 Renal transplant pharmacists in hospitals play a vital role within the transplant team, supporting recipients throughout their journey from surgery to long-term post-transplant care, with a strong focus on medicine management, Ms Tran says.
Renal hospital pharmacists are available in both inpatient and outpatient settings to answer patients’ questions, troubleshoot issues related to specialised medicines and provide guidance on new therapies, she adds. They provide support to ensure changes in medicines are made safely and are tailored to each patient’s needs. Renal pharmacists can also provide the patient with information about kidney medicines and initiate suitable and tailored support.
This can be done in inpatient wards, outpatient clinics and via telehealth, with renal pharmacists able to help relieve CKD symptoms such as water retention, swelling, common uraemic symptoms (itchiness, muscle cramps, fatigue and weakness, ongoing nausea and poor appetite, deterioration in memory), and chronic neuropathic pain.
At bigger hospitals, renal pharmacists work with dialysis units to ensure renal medicines such as erythropoietin injections, dialysis-related blood thinners and iron infusions are appropriately supplied and used safely, Ms Tran adds.
‘Patients who are new to dialysis receive a comprehensive medication review to ensure their current medicines are still suitable for dialysis,’ she says.
‘Patients receive thorough education about how and why some medicines would be dialysed or interact with dialysis, and how and why blood and antidiabetic medication requirements could significantly change when a patient is undergoing dialysis.’
Trials have found that optimal medicine use can significantly reduce the risk of kidney failure while also contributing to the delay or prevention of dialysis.
‘SGLT2 inhibitors can significantly slow the progression of CKD and reduce the risk of needing dialysis in patients with and without type 2 diabetes,’ a meta-analysis research paper concluded. ‘These effects were shown consistently across groups with varying baseline eGFR values.’ 13
The future of pharmacy care
As the medicines experts in the healthcare team, pharmacists are essential for ensuring safe and effective pharmacotherapy in kidney disease patients, Ms Robson says.
‘Besides the traditional roles of verifying dose accuracy and reviewing drug interactions, pharmacists can recommend treatments – such as ACE inhibitors and SGLT2 inhibitors – that have been shown to slow the progression of kidney disease,’ she says.
Pharmacists can also offer self-management counselling, review the potential symptoms of worsening kidney function, provide advice on adverse effects from medicines, and assist with strategies for medicine adherence, she adds.
‘At Kidney Health Australia, we welcome any initiative that will improve outcomes for people living with kidney disease – it is absolutely necessary that we place greater focus on the early detection, diagnosis and management of CKD, and pharmacists are well placed to do this,’ Ms Robson says.
‘Kidney Health Australia has recently partnered with the Pharmaceutical Society of
Australia to deliver educational programs to primary care providers and pharmacists in the community, stressing the need for at-risk patients to get a Kidney Health Check.’
Patient care and screening initiatives in community pharmacy, she adds, will allow pharmacists to play a key role in supporting Kidney Health Australia’s goal of ending
dialysis by 2050.
References
- Kidney Health Australia. Symptoms of kidney disease. At: https://kidney.org.au/your-kidneys/what-is-kidney-disease/symptoms-of-kidney-disease
- National Kidney Foundation. Pharmacists and chronic kidney disease. At: https://www.kidney.org/professionals/ckdintercept/pharmacists-and-chronic-kidney-disease
- Kidney Health Australia. Kidney health check. At: https://kidney.org.au/your-kidneys/know-your-kidneys/know-the-risk-factors/kidney-health-check
- Tesfaye W, Krass I, Sud K, Johnson DW, Van C, Versace VL, et al. Impact of a pharmacy-led screening and intervention in people at risk of or living with chronic kidney disease in a primary care setting: a cluster randomised trial protocol. BMJ Open. 2023;13(12):e079110. At: https://bmjopen.bmj.com/content/13/12/e079110. BMJ Open
- Ardavani A, Curtis F, Hopwood E, et al. Effect of pharmacist interventions in chronic kidney disease: a meta-analysis. Nephrol Dial Transplant. 2025;40(5):884–907. At: https://academic.oup.com/ndt/article/40/5/884/7816383
- Australian Indigenous HealthInfoNet. Latest information and statistics on kidney health. At: https://healthinfonet.ecu.edu.au/learn/health-topics/kidney/latest-information-and-statistics-on-kidney-health/
- CARI Guidelines. First Nations Australian guidelines. At: https://www.cariguidelines.org/first-nations-australian-guidelines/
- Closing the Gap. At: https://www.closingthegap.gov.au
- Oosting IJ, Colombijn JMT, Kaasenbrood L, Liabeuf S, Laville SM, Hooft L, et al. Polypharmacy in patients with CKD: a systematic review and meta-analysis. Kidney360. 2024;5(6):841–850. At: https://pubmed.ncbi.nlm.nih.gov/38661553/. ScienceDirect+1
- Wright J, Glenister KM, Thwaites R, Terry D. The importance of adequate referrals for chronic kidney disease management in a regional Australian area of nephrologist workforce shortage. Aust J Gen Pract. 2018;47(1–2):58–62. At: https://www1.racgp.org.au/ajgp/2018/january-february/the-importance-of-adequate-referrals-for-chronic-k
- Pharmaceutical Society of Australia. Australian Pharmaceutical Formulary. At: https://www.psa.org.au/media-publications/australian-pharmaceutical-formulary/
- Watters TK, Scholes-Robertson NJ, Mallett AJ, Glass BD. Exploring the pharmacist's role in regional, rural, and remote kidney transplant care: Perspectives of health professionals and transplant recipients. Explor Res Clin Soc Pharm. 2025;18:100587. doi:10.1016/j.rcsop.2025.100587. PMID: 40177655; PMCID: PMC11964747
- Mahendra AI, Samsu N, Gunawan A, Rifai A. SGLT-2 inhibitors delay kidney failure progression and reduce need of dialysis in chronic kidney disease patients: a meta-analysis. Nephrol Dial Transplant. 2023;38(Supplement_1):gfad063c_2934. At: https://academic.oup.com/ndt/article/38/Supplement_1/gfad063c_2934/7196059
[post_title] => Finding the missing millions with CKD
[post_excerpt] => From early detection to screening and medicine management – pharmacists are increasingly involved in reducing the burden of kidney disease.
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[post_content] => Case scenario
Fernando, a 16-year-old student, walks into your pharmacy concerned about a rough, painful lesion on the bottom of his foot. He informs you that he has been picking at it, as it has been bothering him, to the point that he is now limping and avoiding sports (football and swimming). He has not tried any treatments, but he has ‘Googled’ it.
On examination, you notice a thickened and tender lesion with black dots on the surface. He is not taking any regular medicines and is otherwise healthy.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
A cutaneous wart is a common, viral skin growth caused by the human papillomavirus (HPV). They are typically classified based on their location on the body and their structure.1 Warts are generally classified as1,2:
Most warts are harmless. Without active treatment, warts will disappear on their own within months to years.1,2 Occasionally, warts can cause discomfort, cosmetic concern or cause temporary functional impairment (e.g. plantar warts).2 Once active treatment is started, persistence is key to ensuring optimal eradication.2
Cutaneous warts are common, particularly among children, adolescents, and individuals who are immunocompromised. Globally, the prevalence of cutaneous warts varies between 7% and 12% in the general population, with the highest rates reported among school-aged children (10–20%).3
In Australia, the most frequently observed types of cutaneous warts are common warts (verruca vulgaris) on hands and knees, and plantar warts (verruca plantaris) on the soles of the feet.2 Studies have found that approximately one-quarter (24%) of school children have had at least one wart, with a significantly higher prevalence observed among those who swim regularly or share footwear.4
Warts are caused by infection with specific types of HPV, of which more than 200 genotypes have been identified.3 Of those, types 1, 2, 4, 27 and 57 are most commonly associated with cutaneous warts.1,3 HPV is transmitted via direct contact with infected skin or indirectly through contaminated environments (e.g. communal showers, swimming pool decks, or gym mats).1–3 HPV can survive for days on surfaces, facilitating indirect spread.6
Once HPV breaches the skin barrier, it infects basal keratinocytes within the epidermis. The virus then induces proliferation of keratinocytes without inducing cell lysis or triggering a significant immune response, thereby evading immune detection.6 As infected cells differentiate and migrate toward the skin surface, viral replication continues, giving rise to the following characteristic histopathological changes that produce the rough, raised appearance of warts5:
Since viral activity remains confined to the epidermis and does not invade deeper tissues, the lesions are typically benign.6
Several factors influence susceptibility to cutaneous warts.
Age
Cutaneous warts are frequently observed in children and adolescents.1 Prevalence tends to decline in adulthood.7
Skin trauma
Cuts, abrasions or frequent friction facilitate viral entry by disrupting the skin barrier, thereby increasing susceptibility.1,2
Immunosuppression
Individuals who are immunocompromised (e.g. those with HIV infection), recipients of organ transplants, or patients receiving immunosuppressive therapy are more prone to persistent and treatment-resistant warts.1
Occupational or recreational exposure
Certain individuals are placed at increased risk due to their environment, such as butchers (susceptible to abrasions, cuts), swimmers (prolonged exposure to moist, communal environments) and athletes (increased skin to skin transmission in contact sports and shared equipment). Overall risk is generally increased with close contact and communal environments, although evidence varies among studies.3
Poor skin hygiene and occlusion
Excess moisture and skin maceration compromise the integrity of the epidermis, creating favourable conditions for infection. 2,3
Atopic dermatitis
A compromised skin barrier may increase susceptibility.1,5
Warts typically have the following presentation5:
Warts range in size from a few millimetres to over a centimetre in diameter and characteristically disrupt normal skin lines.5 They may occur as solitary lesions or in clusters, sometimes coalescing into plaques, particularly in immunocompromised individuals.8
Table 1 summarises the distinguishing features that differentiates subtypes.
Symptoms
Most cutaneous warts are asymptomatic, but they may cause pain, itching or tenderness, especially when located on pressure points like the feet or periungual areas.5,6 Cosmetic distress and social embarrassment are common, particularly for visible or facial warts.8
Diagnosis
Cutaneous warts are diagnosed clinically, based on their appearance, location and patient history.1,3,8 Several skin conditions may resemble the appearance of cutaneous warts5,8:
A thorough patient history, lesion inspection, and understanding of risk factors can aid in distinguishing benign warts from conditions that may require further investigation or treatment.3
Prognosis
The prognosis for cutaneous warts is generally favourable, with most cases being self-limiting. Spontaneous resolution occurs in 50–70% of cases within 2 years, particularly in children and adolescents.4,5
The likelihood of resolution depends on several factors, including patient age, immune status and lesion characteristics.8 Younger patients typically experience higher clearance rates, while those who are immunocompromised may develop more extensive and persistent disease.1 Warts located on plantar or periungual sites, as well as larger lesions, tend to be more resistant to resolution.6
Even without treatment, the immune system can eventually clear the virus.2 However, recurrence is possible, and reinfection may occur via autoinoculation (self-spread from one site on the body to another) or contact with contaminated surfaces.2
The primary aim of treatment for cutaneous warts is to stimulate a host immune response against HPV, often by inducing irritation or inflammation within the lesion.10 By doing so, the following can be achieved3,6,10:
Importantly, patients should be educated that no treatment guarantees 100% success, and that multiple treatment sessions and sustained compliance may be required. Notably, one-third of warts resolve spontaneously within 3 months and two–thirds resolve in 2 years.5,9
Management should be individualised, considering the patient’s age, immune status, wart type, number, location, duration and impact on quality of life.5
Monitoring
In children or patients with recent-onset warts that are not painful or distressing, simply waiting and monitoring is a reasonable option.5,8 This approach may be preferred in young children where treatments may cause discomfort.
Salicylic acid
Salicylic acid (SA) at a concentration of 15–40% is considered the first-line pharmacological treatment for most cutaneous warts.5,9 As a keratolytic agent, it works by softening and progressively removing hyperkeratotic tissue.9 Treatment involves daily application, often for up to 12 weeks.9,10 Evidence indicates that efficacy of SA is improved when the wart is soaked in warm water for 5–10 minutes followed by mechanical debridement, such as paring or filing the lesion prior to application, as this improves penetration of SA into affected tissue.2,10
SA preparations available in community pharmacy include solutions, paints, sticks and pens that are applied daily,9 and medicated discs that are typically left on for 48 hours and repeated for up to 12 weeks as required.7,8
Evidence for the use of SA as a first-line option has shown a cure rate of up to 75% when compared to placebo.9
Adverse effects such as local irritation, blistering or pain are common following SA application.2 Covering the wart with occlusive tape after applying SA helps to prevent contact with healthy skin.10
Salicylic acid with lactic acid and podophyllum resin
Lactic acid is a keratolytic agent that softens and breaks down the thickened skin of warts, helping them shed more easily. It is often combined with SA in topical treatments to enhance removal and promote healthy skin regeneration.10
Podophyllum resin is available in some OTC products and is typically combined with salicylic and lactic acids to treat stubborn common warts. Its active compound, podophyllotoxin, arrests cell division and destroys wart tissue.2,8 Because systemic absorption can cause toxicity, products are applied sparingly to intact skin and avoided in pregnancy or on large or inflamed areas. 2,9 Higher-strength podophyllotoxin for anogenital warts is Schedule 4 (Prescription Only).2
Cryotherapy
Cryotherapy is a second-line option for adults or older children with painful, persistent, or cosmetically concerning warts.9 Cryotherapy with liquid nitrogen (through a medical practitioner) or dimethyl ether and propane (DMEP), a non-prescription product, induces tissue necrosis through freezing.8,9 Non-prescription DMEP products are colder than ambient but do not reach liquid nitrogen temperatures and are typically less effective.10
Cryotherapy is usually administered at intervals of 2–3 weeks for up to 12 weeks, with multiple sessions often required for optimal clearance.9 The procedure can be painful, so its use is typically avoided in young children.9
Adverse effects include pain, blistering and pigmentation changes. Its efficacy is comparable to SA when compliance to therapy is high.3,9
Alternative or specialist treatment
In cases where first- and second-line therapy fails, patients may be referred for specialist treatments. Options include immunotherapy (e.g. topical imiquimod), intralesional antigen injections, as well as procedural approaches, such as laser therapy or electrosurgery.3,8,9
Imiquimod stimulates local immune responses and may be used off-label for cutaneous warts, particularly recalcitrant (resistant to treatment) or widespread cases.5,8,9 While evidence is limited for non-genital warts, it remains an option for referral or specialist use.9
Laser therapy, curettage and surgical excision are typically reserved for warts not responding to conservative measures.3 These options carry risks such as scarring and are performed in specialist settings.2,9
Referral should be considered for immunocompromised patients, for lesions with features suggestive of skin cancer, in cases of extensive or treatment-resistant warts, and bleeding or rapidly growing lesions.9
Other therapies
Occlusion – duct tape
Occlusion with duct tape is a low-cost method that involves covering the wart with duct tape and changing it weekly with periodic debridement.9 Although evidence is mixed,9 it is a well-tolerated adjunct or alternative in paediatric cases, or for patients preferring non-chemical options.8 Patient expectations should be modest.9
Zinc
Oral and topical zinc have been studied in wart treatment due to their immunomodulatory properties.9 Oral zinc has been shown to be effective at treating recalcitrant warts when administered at therapeutic doses.8 However, evidence is limited, and results across studies have been mixed. 8 Its role in routine management remains uncertain.9
Treatment considerations
Treatment of cutaneous warts requires persistence.3 Many patients may discontinue therapy prematurely, often due to perceived lack of efficacy, highlighting the importance of counselling around expected treatment duration.1-3
Adverse effects such as local irritation, blistering, or pain are common.1 Inappropriately applied SA or cryotherapy can damage surrounding skin, spread the virus or lead to secondary infection.10 The use of petroleum jelly around the lesion or tape over the lesion is recommended to protect surrounding healthy skin.10
Other skin conditions can mimic the presentation of cutaneous warts, thereby requiring alternative management. Lesions that bleed, ulcerate or change in appearance should also prompt further assessment.
Precautions
Children, people with diabetes and those who are immunocompromised may present as more complicated cases or have contraindications to standard therapy.8,9 Avoid the use of keratolytic agents and aggressive debridement in patients with diabetes or peripheral vascular disease, as acute inflammation and ulceration may occur.2 Plantar warts in people with diabetes require cautious management, as neuropathy and impaired circulation increase the risk of ulceration, secondary infection and delayed wound healing.6 Alternative treatments or referral to a GP or dermatologist may be required.
Children are more sensitive to irritation and systemic absorption of active ingredient, therefore keratolytic agents should be used with caution. However, SA can be used in children with careful application and skin protection, avoiding large areas or irritated skin.2
Complications
Secondary infection
Warts that are irritated by scratching, shaving or treatment can become infected. The need for good hygiene practices and protecting the lesion site is important.6 Educate patients about signs of infection, such as4–6:
Patients should be advised to withhold treatment and refer to a GP if signs of infection are present.
Pain and irritation
Plantar warts may become painful due to pressure while walking.6 The use of keratolytics and cryotherapy can result in additional pain.
To prevent discontinuation of treatment, cushioning for plantar warts (e.g. with felt pads) may be recommended to alleviate discomfort,6 or advise patients on appropriate analgesia if needed.
Overuse or misapplication of topical treatments can cause irritant contact dermatitis or chemical burns. Precise application and protective measures can minimise irritation.10 Treatments for warts can potentially lead to scarring.10
Spread and recurrence
Immunosuppression8 and local trauma, especially when adjacent healthy skin is accidentally pared prior to application of keratolytic treatments, can increase the risk of spread to adjacent areas. Recurrence is common and does not necessarily indicate treatment failure.1,6,10
Follow-up
Warts commonly require up to 12 weeks of therapy to achieve clinical resolution, especially with non-prescription treatments.2 Without structured follow-up, patients may discontinue treatment prematurely due to slow response, leading to treatment failure or recurrence.
Pharmacists play an important role in the early identification, treatment, education and monitoring of cutaneous warts. By taking a thorough history when patients present with skin concerns, pharmacists can assist with timely intervention, reducing transmission and preventing complications.1
Pharmacists may recommend first-line therapies such as SA and guide patients on correct use to optimise outcomes and minimise adverse effects.
Pharmacists can also provide education and counselling on the viral nature of warts, transmission routes and treatment expectations.
Importantly, pharmacists are positioned to encourage patients to return for follow-up if progress is sub-optimal, allowing ongoing monitoring of adherence, response or the need to refer.1,2,10
Pharmacists must be able to recognise red flags, such as non-resolving lesions, sensitive anatomical locations or immunocompromised status, and refer to GPs for further management.8
An important part of counselling involves explaining the likelihood of wart recurrence and emphasising the role of good hygiene in reducing the risk of infection.1,2,10
Conclusion
Cutaneous warts are common and generally have a favourable prognosis, with many resolving spontaneously within months to years. However, people often seek treatment to improve cosmetic appearance or reduce discomfort.2 Warts may persist, recur or become susceptible to secondary infection if inappropriately treated.1,2,10
Pharmacists play an active role in treatment by identifying warts, advising on treatment, counselling on correct application, and identifying when referral may be required.
Case scenario continuedYou explain to Fernando that the lesion is consistent with a plantar wart and recommend starting a combination salicylic acid and lactic acid preparation with nightly application following debridement. You counsel on application technique, the importance of good hygiene and remaining consistent with treatment. You encourage him to return in 2 weeks for review, and when he presents, you find it is noticeably reduced and no longer painful. You advise him to continue with treatment until it disappears, but not for longer than 12 weeks, and to remain vigilant for signs of infection or recurrence. Fernando is grateful for your help and soon returns to participating in sports. |
Diyar Emadi MBA, BPharm, CredPharm (MMR), CDE, CPT, SCOPE certified, MPS is a credentialed pharmacist and diabetes educator with expertise in insulin pumps, obesity and weight management. Founder of Synergy Medicine Consulting, he works as a consultant pharmacist in general practice and as a diabetes educator alongside endocrinologists in specialist practice. With an MBA and a background spanning community, hospital and pharmaceutical industry roles, Diyar brings clinical and strategic insight to his work as a medical writer.
Sharon Ambalal MPH, BPharm, MPS
[post_title] => Cutaneous warts in community practice [post_excerpt] => Pharmacists play an important role in the early identification, treatment, education and monitoring of cutaneous warts. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => cutaneous-warts-in-community-practice [to_ping] => [pinged] => [post_modified] => 2025-12-17 17:00:00 [post_modified_gmt] => 2025-12-17 06:00:00 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=30883 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Cutaneous warts in community practice [title] => Cutaneous warts in community practice [href] => https://www.australianpharmacist.com.au/cutaneous-warts-in-community-practice/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 31108 [authorType] => )td_module_mega_menu Object
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[post_content] => The most-read stories of the year highlight where clinical practice, regulation and professional reform collided.
From sweeping Therapeutic Guidelines updates to unresolved scheduling decisions and award wage reform, these five stories captured pharmacists’ attention and reflected the pressures shaping practice in 2025.
1. Therapeutic Guidelines overhaul UTI treatment
The Therapeutic Guidelines on antibiotics underwent the biggest update in TG history, encompassing 1,400 medicine recommendations to reflect new evidence and rising antimicrobial resistance.
The first stage targeted infections managed in primary care, with one of the most significant shifts made to the management of urinary tract infections (UTIs). Trimethoprim is no longer first-line therapy for uncomplicated cystitis in non-pregnant adults due to resistance in Escherichia coli (E. coli). Instead, nitrofurantoin is now recommended as the preferred first-line option, with fosfomycin and cefalexin listed as alternatives.
This update impacted pharmacists offering UTI treatment services nationwide, particularly in states such as New South Wales – where trimethoprim was previously first-line therapy.
2. Is Rikodeine still being rescheduled?
Last year, the TGA made an interim decision to upschedule dihydrocodeine due to concerns about potential misuse, abuse and dependence. The TGA Delegate’s interim decision was to amend the Pharmacist Only entry for dihydrocodeine to restrict undivided oral liquid preparations to a maximum primary pack size of 100 mL from 1 October 2025.
But the final decision is yet to be published, with a public consultation process causing the delay. In September 2024, the TGA confirmed that final decisions had been deferred while the consultation responses were further considered.
In the meantime, dihydrocodeine scheduling remains unchanged – with pharmacists continuing to field frequent requests for Rikodeine, often from patients without symptoms of dry cough.
3. Hiprex becomes a Pharmacist Only medicine
Methenamine hippurate, sold as Hiprex and Uramet, officially became a Pharmacist Only medicine on 1 October 2025. Previously unscheduled and available as a general sales medicine, the aim of the change was to ensure pharmacist oversight and safer use.
While a Pharmacy Only designation was considered, the TGA concluded this would not prevent inappropriate use among people who have not been medically assessed.
4. What you need to know about the paracetamol regulation changes
From 1 February 2025, paracetamol pack sizes sold in pharmacies changed as part of the TGA’s final decision on paracetamol access controls. Packs containing 50–100 tablets or capsules became Pharmacist Only medicines and general-sale pack sizes reduced from 20 to 16 tablets, among other changes – with the aim of reducing the amount of paracetamol stored in households to prevent harm from intentional overdose.
Each year, around 225 Australians are hospitalised with liver injury due to paracetamol overdose, with the highest rates among adolescents and young adults, particularly females.
Pharmacists should act as ‘champions for the change’, reinforcing safe use and helping to limit surplus paracetamol in homes, said PSA Senior Pharmacist – Strategic Policy, Peter Guthrey MPS at the time.
‘The data on intentional overdose involving paracetamol is alarming … scheduling changes are not the full solution, but are a strategy which could make a positive difference if it changes the patterns of paracetamol supply,’ he said.
5. Fair Work publishes gender undervaluation decision on pharmacist award
In April, the Fair Work Commission’s Expert Panel for pay equity in the care and community sector issued its initial decision on the Gender-based undervaluation – priority awards review, making significant determinations for the Pharmacy Industry Award 2020, under which most community pharmacists are employed.
The Expert Panel found that pharmacists covered by the award have been subject to gender-based undervaluation, with the assessment considering factors such as:
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[post_content] => New year, new policy and practice changes. Here’s what pharmacists will need to navigate from January.
In 2026, pharmacists can expect some changes to education, medicine costs and credentialing standards.
AP has rounded up the key changes pharmacists can expect from 1 January.
1. PBS co‑payment will drop
From 1 January 2026, the maximum Pharmaceutical Benefits Scheme (PBS) co‑payment for general patients will drop from $31.60 to $25.00 per prescription.
This marks a major reduction in out-of-pocket costs for Australians without a concession card, and the first time in more than 20 years that PBS medicines will cost no more than $25.
However, indexation on the general patient co-payment will resume in 2027 in line with the Consumer Price Index (CPI). Although PBS medicines will not be permanently capped at $25, the long‑term trajectory of general patient co‑payments will rise from a much lower baseline.
2. Transition to the new MMR credential must be completed
By 1 January 2026, pharmacists must have transitioned to the APC’s new Medication Management Review credential to continue:
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[post_content] => The Pharmaceutical Society of Australia (PSA) recently launched the PSA Standards for Continuing Professional Development (CPD) for Pharmacists, marking a new era for the accreditation of CPD activities for the pharmacy profession.
The launch of the PSA Standards follows the retirement of the Australian Pharmacy Council (APC) Accreditation Standards for CPD Activities on 31 December 2025. Developed through extensive consultation with the profession, the PSA Standards provide a contemporary framework to guide the quality and educational integrity of continuing professional development activities for pharmacists.
With the commencement of these Standards, CPD providers can apply for accreditation under the PSA Accredited CPD framework.
All supporting materials, including application forms and the PSA Accredited CPD Provider Handbook, will be available on the PSA website from 5 January 2026.
PSA acknowledges and thanks the individuals and organisations who contributed feedback during the consultation process and looks forward to supporting providers in delivering high-quality education for pharmacists.
PSA National President Associate Professor Fei Sim FPS reflected on the process of developing the Standards, acknowledging the work of all involved, including the individuals and organisations who provided feedback during the consultation period.
“The approval of the PSA standards for CPD for pharmacists marks a significant milestone in PSA’s already rich history in upholding quality education standards, now spanning decades,” she said.
“We know our education and continuing professional development are core values for our members. I want to assure you that these standards will give pharmacists the confidence that the CPD they access is of high quality.
“I sincerely thank everyone who participated in the consultation process. It is an incredible achievement to be sharing this news only 5 months after announcing PSA’s intent to publish these education standards.”
To view the Standards or enquire about the accreditation process, please visit https://www.psa.org.au/cpd/
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[post_content] => From early detection to screening and medicine management – pharmacists are increasingly involved in reducing the burden of kidney disease.
Chronic kidney disease (CKD) is a common but often ‘silent’ condition. One in three Australians are at risk of developing progressive CKD resulting from comorbidities such as hypertension, diabetes and cardiovascular disease. And most people are asymptomatic until significant kidney damage has occurred.
Familiarity with patients’ medical history equips pharmacists to act as first identifiers of potential CKD and to suggest Kidney Health Checks – which can find CKD in time to better manage the condition. People with diabetes, hypertension, family history of kidney disease, or those who are over 18 and from an Aboriginal and Torres Strait Islander family should have annual Kidney Health Checks. Current smokers and people with other risk factors, such as cardiovascular disease or obesity, should have Kidney Health Checks every 2 years.
Screening for CKD
A trial of CKD screening by pharmacists is currently underway across Australia, covering nearly 1,500 patients in 192 community pharmacies.
According to the University of Sydney’s Associate Professor Ron Castelino, a practising renal pharmacist at Blacktown Hospital, the trial was inspired by the discrepancy between the routine kidney function test results available to hospital pharmacists – who can then adjust doses of medicines cleared by the kidneys – and the lack of information available to community pharmacists.
The pilot first required pharmacists to assess patients’ likelihood of developing CKD using a series of questions about their risk factors. Around 30% of the patients in the recruitment pool were assessed as having a moderate to severe risk of developing CKD within 5 years. They were offered a point-of-care kidney function test, which is essentially a finger-prick test similar to the glucometer test used to manage diabetes, A/Prof Castelino says.
The point-of-care test provides an immediate reading of the patient’s estimated glomerular filtration rate (eGFR) and levels of serum creatinine to measure how well the kidneys are filtering waste from the blood. Patients identified as having impaired kidney function are referred to their general practitioner (GP) for more comprehensive blood and urine tests, spaced over at least 3 months, to diagnose CKD, he adds.
‘There are two or three benefits that I see straight away with the point-of-care device screening, particularly in rural and remote areas where pharmacy is more accessible,’ A/Prof Castelino says.
‘Patients can walk in and get the finger-prick test as the initial screening. Those who do come up with a decline in kidney function can be referred to the doctor straightaway, so that’s a massive positive. It’s also a good opportunity for pharmacists to see whether the dosage of medicines cleared by the kidneys may need to be adjusted.’
Management in pharmacy
Pharmacists’ therapeutic knowledge puts them in a unique position to help people manage CKD. A recent systematic review and meta-analysis of randomised controlled trials – including adults with a diagnosis of CKD and those with and without kidney replacement therapy – found pharmacist interventions resulted in statistically significant improvements
in systolic blood pressure and haemoglobin levels.5
But the findings showed pharmacist interventions had mixed results for various outcomes, according to the scientists. ‘Future studies should be more robustly designed and take into consideration the role of the pharmacist in prescribing and deprescribing, the findings of which will help inform research and clinical practice,’ they concluded.5
Kidney care for Aboriginal and Torres Strait Islander peoples
Chronic kidney disease is prevalent among Aboriginal and Torres Strait Islander peoples.6 Breonny Robson, Kidney Health Australia’s General Manager, Clinical and Research, says pharmacists should familiarise themselves with the Caring for Australians and New Zealanders with Kidney Impairment (CARI) recommendations for providing culturally safe kidney care in Aboriginal and Torres Strait Islander peoples.7
‘Pharmacists should also ensure pharmacy staff undertake formal cultural safety training and establish that they have referral pathways for First Nations peoples back to their local Aboriginal Community Controlled Health Organisations (ACCHOs) and GP to ensure continuity of care,’ she says.
‘First Nations peoples should be encouraged to have their annual 715 health check [the Medicare number for a comprehensive health check], ensure that they are correctly identified as Aboriginal and/or Torres Strait Islander at the service and that they are correctly enrolled in the Closing the Gap program.’8
Ms Robson adds that pharmacists should discuss potential point-of-care testing and in-pharmacy screening with the local ACCHO, so that community members are linked to their regular health service for continuity of care.
Pharmacists supporting CKD treatment
CKD usually entails ‘super-polypharmacy’.9 With patients often managing 16–20 medicines, pharmacists have a vital role to play in medicines review, dose adjustment and transplant support.
Hanh Tran, Senior Pharmacist (Renal) at Royal Adelaide Hospital, says polypharmacy is a significant challenge in CKD due to patients’ unstable renal function, their frequent medicines changes, and the involvement of multiple specialists (including endocrinologists, cardiologists and GPs).
‘Patients often experience “pill burden” and contradictory advice,’ she says. ‘A classic example is calcium: commonly prescribed as a phosphate binder in CKD, it must be taken with food to bind dietary phosphate – which is contrary to the usual advice for calcium supplementation.’
Renal dosing principles include maintaining medicine records, providing patients with updated lists of medicines, and ensuring they are equipped to manage complex medicines regimens.
Ms Tran says that dosing advice should be provided to relevant healthcare providers, including doctors, nurses and nurse practitioners.
Meanwhile, people living with CKD in rural and regional areas may have limited access to nephrology services or dialysis centres.10 Gauri Godbole FPS, a specialist aged care pharmacist at Gosford Hospital, says that in cases of patients with advanced CKD requiring polypharmacy, it’s important to ‘prioritise medicines with clear evidence of benefit that are aligned to patient goals, and ensure renal-appropriate dosing’.
Identifying the patient’s best possible medication history, including the over-the-counter and herbal products they take, is the first step, she says. Ms Godbole then identifies the high-risk or nephrotoxic medicines and recommends dose adjustments or, in certain cases, discontinuation, based on renal function and clinical benefit.
‘Goals of care often evolve over time, serving as an important catalyst for deprescribing,’ she says.
‘We identify nephrotoxic, duplicate or low-value medicines for deprescribing, especially where benefits are limited in advanced illness. Tools such as STOPP/START, STOPPFrail and STOPPCog, alongside multidisciplinary input and shared decision-making, support tailored recommendations. Deprescribing should be monitored with regular follow-up, symptom checks, and tapering if needed.’
The Australian Pharmaceutical Formulary and Handbook (APF) supports the concept of deprescribing in patients with progressive CKD where the benefit of long-term preventive medicines (such as statins in the elderly) may no longer outweigh the risks. Deprescribing should also be considered for medicines with narrow therapeutic windows or renal toxicity such as lithium, NSAIDs, metformin and SGLT2 inhibitors (depending on eGFR).11
The APF recommends assessing kidney function before adjusting dosages and referencing renal dosing guides when determining dose changes. It also recommends avoiding or reducing the dosage of nephrotoxic drugs such as NSAIDs and aminoglycosides, and advises special caution with drugs cleared renally – including metformin (which carries a risk of lactic acidosis), digoxin and DOACs (such as apixaban).11
Providing transplant support
Community pharmacists can provide essential support for kidney transplant recipients in regional, rural and remote areas of Australia.12 Renal transplant pharmacists in hospitals play a vital role within the transplant team, supporting recipients throughout their journey from surgery to long-term post-transplant care, with a strong focus on medicine management, Ms Tran says.
Renal hospital pharmacists are available in both inpatient and outpatient settings to answer patients’ questions, troubleshoot issues related to specialised medicines and provide guidance on new therapies, she adds. They provide support to ensure changes in medicines are made safely and are tailored to each patient’s needs. Renal pharmacists can also provide the patient with information about kidney medicines and initiate suitable and tailored support.
This can be done in inpatient wards, outpatient clinics and via telehealth, with renal pharmacists able to help relieve CKD symptoms such as water retention, swelling, common uraemic symptoms (itchiness, muscle cramps, fatigue and weakness, ongoing nausea and poor appetite, deterioration in memory), and chronic neuropathic pain.
At bigger hospitals, renal pharmacists work with dialysis units to ensure renal medicines such as erythropoietin injections, dialysis-related blood thinners and iron infusions are appropriately supplied and used safely, Ms Tran adds.
‘Patients who are new to dialysis receive a comprehensive medication review to ensure their current medicines are still suitable for dialysis,’ she says.
‘Patients receive thorough education about how and why some medicines would be dialysed or interact with dialysis, and how and why blood and antidiabetic medication requirements could significantly change when a patient is undergoing dialysis.’
Trials have found that optimal medicine use can significantly reduce the risk of kidney failure while also contributing to the delay or prevention of dialysis.
‘SGLT2 inhibitors can significantly slow the progression of CKD and reduce the risk of needing dialysis in patients with and without type 2 diabetes,’ a meta-analysis research paper concluded. ‘These effects were shown consistently across groups with varying baseline eGFR values.’ 13
The future of pharmacy care
As the medicines experts in the healthcare team, pharmacists are essential for ensuring safe and effective pharmacotherapy in kidney disease patients, Ms Robson says.
‘Besides the traditional roles of verifying dose accuracy and reviewing drug interactions, pharmacists can recommend treatments – such as ACE inhibitors and SGLT2 inhibitors – that have been shown to slow the progression of kidney disease,’ she says.
Pharmacists can also offer self-management counselling, review the potential symptoms of worsening kidney function, provide advice on adverse effects from medicines, and assist with strategies for medicine adherence, she adds.
‘At Kidney Health Australia, we welcome any initiative that will improve outcomes for people living with kidney disease – it is absolutely necessary that we place greater focus on the early detection, diagnosis and management of CKD, and pharmacists are well placed to do this,’ Ms Robson says.
‘Kidney Health Australia has recently partnered with the Pharmaceutical Society of
Australia to deliver educational programs to primary care providers and pharmacists in the community, stressing the need for at-risk patients to get a Kidney Health Check.’
Patient care and screening initiatives in community pharmacy, she adds, will allow pharmacists to play a key role in supporting Kidney Health Australia’s goal of ending
dialysis by 2050.
References
- Kidney Health Australia. Symptoms of kidney disease. At: https://kidney.org.au/your-kidneys/what-is-kidney-disease/symptoms-of-kidney-disease
- National Kidney Foundation. Pharmacists and chronic kidney disease. At: https://www.kidney.org/professionals/ckdintercept/pharmacists-and-chronic-kidney-disease
- Kidney Health Australia. Kidney health check. At: https://kidney.org.au/your-kidneys/know-your-kidneys/know-the-risk-factors/kidney-health-check
- Tesfaye W, Krass I, Sud K, Johnson DW, Van C, Versace VL, et al. Impact of a pharmacy-led screening and intervention in people at risk of or living with chronic kidney disease in a primary care setting: a cluster randomised trial protocol. BMJ Open. 2023;13(12):e079110. At: https://bmjopen.bmj.com/content/13/12/e079110. BMJ Open
- Ardavani A, Curtis F, Hopwood E, et al. Effect of pharmacist interventions in chronic kidney disease: a meta-analysis. Nephrol Dial Transplant. 2025;40(5):884–907. At: https://academic.oup.com/ndt/article/40/5/884/7816383
- Australian Indigenous HealthInfoNet. Latest information and statistics on kidney health. At: https://healthinfonet.ecu.edu.au/learn/health-topics/kidney/latest-information-and-statistics-on-kidney-health/
- CARI Guidelines. First Nations Australian guidelines. At: https://www.cariguidelines.org/first-nations-australian-guidelines/
- Closing the Gap. At: https://www.closingthegap.gov.au
- Oosting IJ, Colombijn JMT, Kaasenbrood L, Liabeuf S, Laville SM, Hooft L, et al. Polypharmacy in patients with CKD: a systematic review and meta-analysis. Kidney360. 2024;5(6):841–850. At: https://pubmed.ncbi.nlm.nih.gov/38661553/. ScienceDirect+1
- Wright J, Glenister KM, Thwaites R, Terry D. The importance of adequate referrals for chronic kidney disease management in a regional Australian area of nephrologist workforce shortage. Aust J Gen Pract. 2018;47(1–2):58–62. At: https://www1.racgp.org.au/ajgp/2018/january-february/the-importance-of-adequate-referrals-for-chronic-k
- Pharmaceutical Society of Australia. Australian Pharmaceutical Formulary. At: https://www.psa.org.au/media-publications/australian-pharmaceutical-formulary/
- Watters TK, Scholes-Robertson NJ, Mallett AJ, Glass BD. Exploring the pharmacist's role in regional, rural, and remote kidney transplant care: Perspectives of health professionals and transplant recipients. Explor Res Clin Soc Pharm. 2025;18:100587. doi:10.1016/j.rcsop.2025.100587. PMID: 40177655; PMCID: PMC11964747
- Mahendra AI, Samsu N, Gunawan A, Rifai A. SGLT-2 inhibitors delay kidney failure progression and reduce need of dialysis in chronic kidney disease patients: a meta-analysis. Nephrol Dial Transplant. 2023;38(Supplement_1):gfad063c_2934. At: https://academic.oup.com/ndt/article/38/Supplement_1/gfad063c_2934/7196059
[post_title] => Finding the missing millions with CKD
[post_excerpt] => From early detection to screening and medicine management – pharmacists are increasingly involved in reducing the burden of kidney disease.
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[post_content] => Case scenario
Fernando, a 16-year-old student, walks into your pharmacy concerned about a rough, painful lesion on the bottom of his foot. He informs you that he has been picking at it, as it has been bothering him, to the point that he is now limping and avoiding sports (football and swimming). He has not tried any treatments, but he has ‘Googled’ it.
On examination, you notice a thickened and tender lesion with black dots on the surface. He is not taking any regular medicines and is otherwise healthy.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
A cutaneous wart is a common, viral skin growth caused by the human papillomavirus (HPV). They are typically classified based on their location on the body and their structure.1 Warts are generally classified as1,2:
Most warts are harmless. Without active treatment, warts will disappear on their own within months to years.1,2 Occasionally, warts can cause discomfort, cosmetic concern or cause temporary functional impairment (e.g. plantar warts).2 Once active treatment is started, persistence is key to ensuring optimal eradication.2
Cutaneous warts are common, particularly among children, adolescents, and individuals who are immunocompromised. Globally, the prevalence of cutaneous warts varies between 7% and 12% in the general population, with the highest rates reported among school-aged children (10–20%).3
In Australia, the most frequently observed types of cutaneous warts are common warts (verruca vulgaris) on hands and knees, and plantar warts (verruca plantaris) on the soles of the feet.2 Studies have found that approximately one-quarter (24%) of school children have had at least one wart, with a significantly higher prevalence observed among those who swim regularly or share footwear.4
Warts are caused by infection with specific types of HPV, of which more than 200 genotypes have been identified.3 Of those, types 1, 2, 4, 27 and 57 are most commonly associated with cutaneous warts.1,3 HPV is transmitted via direct contact with infected skin or indirectly through contaminated environments (e.g. communal showers, swimming pool decks, or gym mats).1–3 HPV can survive for days on surfaces, facilitating indirect spread.6
Once HPV breaches the skin barrier, it infects basal keratinocytes within the epidermis. The virus then induces proliferation of keratinocytes without inducing cell lysis or triggering a significant immune response, thereby evading immune detection.6 As infected cells differentiate and migrate toward the skin surface, viral replication continues, giving rise to the following characteristic histopathological changes that produce the rough, raised appearance of warts5:
Since viral activity remains confined to the epidermis and does not invade deeper tissues, the lesions are typically benign.6
Several factors influence susceptibility to cutaneous warts.
Age
Cutaneous warts are frequently observed in children and adolescents.1 Prevalence tends to decline in adulthood.7
Skin trauma
Cuts, abrasions or frequent friction facilitate viral entry by disrupting the skin barrier, thereby increasing susceptibility.1,2
Immunosuppression
Individuals who are immunocompromised (e.g. those with HIV infection), recipients of organ transplants, or patients receiving immunosuppressive therapy are more prone to persistent and treatment-resistant warts.1
Occupational or recreational exposure
Certain individuals are placed at increased risk due to their environment, such as butchers (susceptible to abrasions, cuts), swimmers (prolonged exposure to moist, communal environments) and athletes (increased skin to skin transmission in contact sports and shared equipment). Overall risk is generally increased with close contact and communal environments, although evidence varies among studies.3
Poor skin hygiene and occlusion
Excess moisture and skin maceration compromise the integrity of the epidermis, creating favourable conditions for infection. 2,3
Atopic dermatitis
A compromised skin barrier may increase susceptibility.1,5
Warts typically have the following presentation5:
Warts range in size from a few millimetres to over a centimetre in diameter and characteristically disrupt normal skin lines.5 They may occur as solitary lesions or in clusters, sometimes coalescing into plaques, particularly in immunocompromised individuals.8
Table 1 summarises the distinguishing features that differentiates subtypes.
Symptoms
Most cutaneous warts are asymptomatic, but they may cause pain, itching or tenderness, especially when located on pressure points like the feet or periungual areas.5,6 Cosmetic distress and social embarrassment are common, particularly for visible or facial warts.8
Diagnosis
Cutaneous warts are diagnosed clinically, based on their appearance, location and patient history.1,3,8 Several skin conditions may resemble the appearance of cutaneous warts5,8:
A thorough patient history, lesion inspection, and understanding of risk factors can aid in distinguishing benign warts from conditions that may require further investigation or treatment.3
Prognosis
The prognosis for cutaneous warts is generally favourable, with most cases being self-limiting. Spontaneous resolution occurs in 50–70% of cases within 2 years, particularly in children and adolescents.4,5
The likelihood of resolution depends on several factors, including patient age, immune status and lesion characteristics.8 Younger patients typically experience higher clearance rates, while those who are immunocompromised may develop more extensive and persistent disease.1 Warts located on plantar or periungual sites, as well as larger lesions, tend to be more resistant to resolution.6
Even without treatment, the immune system can eventually clear the virus.2 However, recurrence is possible, and reinfection may occur via autoinoculation (self-spread from one site on the body to another) or contact with contaminated surfaces.2
The primary aim of treatment for cutaneous warts is to stimulate a host immune response against HPV, often by inducing irritation or inflammation within the lesion.10 By doing so, the following can be achieved3,6,10:
Importantly, patients should be educated that no treatment guarantees 100% success, and that multiple treatment sessions and sustained compliance may be required. Notably, one-third of warts resolve spontaneously within 3 months and two–thirds resolve in 2 years.5,9
Management should be individualised, considering the patient’s age, immune status, wart type, number, location, duration and impact on quality of life.5
Monitoring
In children or patients with recent-onset warts that are not painful or distressing, simply waiting and monitoring is a reasonable option.5,8 This approach may be preferred in young children where treatments may cause discomfort.
Salicylic acid
Salicylic acid (SA) at a concentration of 15–40% is considered the first-line pharmacological treatment for most cutaneous warts.5,9 As a keratolytic agent, it works by softening and progressively removing hyperkeratotic tissue.9 Treatment involves daily application, often for up to 12 weeks.9,10 Evidence indicates that efficacy of SA is improved when the wart is soaked in warm water for 5–10 minutes followed by mechanical debridement, such as paring or filing the lesion prior to application, as this improves penetration of SA into affected tissue.2,10
SA preparations available in community pharmacy include solutions, paints, sticks and pens that are applied daily,9 and medicated discs that are typically left on for 48 hours and repeated for up to 12 weeks as required.7,8
Evidence for the use of SA as a first-line option has shown a cure rate of up to 75% when compared to placebo.9
Adverse effects such as local irritation, blistering or pain are common following SA application.2 Covering the wart with occlusive tape after applying SA helps to prevent contact with healthy skin.10
Salicylic acid with lactic acid and podophyllum resin
Lactic acid is a keratolytic agent that softens and breaks down the thickened skin of warts, helping them shed more easily. It is often combined with SA in topical treatments to enhance removal and promote healthy skin regeneration.10
Podophyllum resin is available in some OTC products and is typically combined with salicylic and lactic acids to treat stubborn common warts. Its active compound, podophyllotoxin, arrests cell division and destroys wart tissue.2,8 Because systemic absorption can cause toxicity, products are applied sparingly to intact skin and avoided in pregnancy or on large or inflamed areas. 2,9 Higher-strength podophyllotoxin for anogenital warts is Schedule 4 (Prescription Only).2
Cryotherapy
Cryotherapy is a second-line option for adults or older children with painful, persistent, or cosmetically concerning warts.9 Cryotherapy with liquid nitrogen (through a medical practitioner) or dimethyl ether and propane (DMEP), a non-prescription product, induces tissue necrosis through freezing.8,9 Non-prescription DMEP products are colder than ambient but do not reach liquid nitrogen temperatures and are typically less effective.10
Cryotherapy is usually administered at intervals of 2–3 weeks for up to 12 weeks, with multiple sessions often required for optimal clearance.9 The procedure can be painful, so its use is typically avoided in young children.9
Adverse effects include pain, blistering and pigmentation changes. Its efficacy is comparable to SA when compliance to therapy is high.3,9
Alternative or specialist treatment
In cases where first- and second-line therapy fails, patients may be referred for specialist treatments. Options include immunotherapy (e.g. topical imiquimod), intralesional antigen injections, as well as procedural approaches, such as laser therapy or electrosurgery.3,8,9
Imiquimod stimulates local immune responses and may be used off-label for cutaneous warts, particularly recalcitrant (resistant to treatment) or widespread cases.5,8,9 While evidence is limited for non-genital warts, it remains an option for referral or specialist use.9
Laser therapy, curettage and surgical excision are typically reserved for warts not responding to conservative measures.3 These options carry risks such as scarring and are performed in specialist settings.2,9
Referral should be considered for immunocompromised patients, for lesions with features suggestive of skin cancer, in cases of extensive or treatment-resistant warts, and bleeding or rapidly growing lesions.9
Other therapies
Occlusion – duct tape
Occlusion with duct tape is a low-cost method that involves covering the wart with duct tape and changing it weekly with periodic debridement.9 Although evidence is mixed,9 it is a well-tolerated adjunct or alternative in paediatric cases, or for patients preferring non-chemical options.8 Patient expectations should be modest.9
Zinc
Oral and topical zinc have been studied in wart treatment due to their immunomodulatory properties.9 Oral zinc has been shown to be effective at treating recalcitrant warts when administered at therapeutic doses.8 However, evidence is limited, and results across studies have been mixed. 8 Its role in routine management remains uncertain.9
Treatment considerations
Treatment of cutaneous warts requires persistence.3 Many patients may discontinue therapy prematurely, often due to perceived lack of efficacy, highlighting the importance of counselling around expected treatment duration.1-3
Adverse effects such as local irritation, blistering, or pain are common.1 Inappropriately applied SA or cryotherapy can damage surrounding skin, spread the virus or lead to secondary infection.10 The use of petroleum jelly around the lesion or tape over the lesion is recommended to protect surrounding healthy skin.10
Other skin conditions can mimic the presentation of cutaneous warts, thereby requiring alternative management. Lesions that bleed, ulcerate or change in appearance should also prompt further assessment.
Precautions
Children, people with diabetes and those who are immunocompromised may present as more complicated cases or have contraindications to standard therapy.8,9 Avoid the use of keratolytic agents and aggressive debridement in patients with diabetes or peripheral vascular disease, as acute inflammation and ulceration may occur.2 Plantar warts in people with diabetes require cautious management, as neuropathy and impaired circulation increase the risk of ulceration, secondary infection and delayed wound healing.6 Alternative treatments or referral to a GP or dermatologist may be required.
Children are more sensitive to irritation and systemic absorption of active ingredient, therefore keratolytic agents should be used with caution. However, SA can be used in children with careful application and skin protection, avoiding large areas or irritated skin.2
Complications
Secondary infection
Warts that are irritated by scratching, shaving or treatment can become infected. The need for good hygiene practices and protecting the lesion site is important.6 Educate patients about signs of infection, such as4–6:
Patients should be advised to withhold treatment and refer to a GP if signs of infection are present.
Pain and irritation
Plantar warts may become painful due to pressure while walking.6 The use of keratolytics and cryotherapy can result in additional pain.
To prevent discontinuation of treatment, cushioning for plantar warts (e.g. with felt pads) may be recommended to alleviate discomfort,6 or advise patients on appropriate analgesia if needed.
Overuse or misapplication of topical treatments can cause irritant contact dermatitis or chemical burns. Precise application and protective measures can minimise irritation.10 Treatments for warts can potentially lead to scarring.10
Spread and recurrence
Immunosuppression8 and local trauma, especially when adjacent healthy skin is accidentally pared prior to application of keratolytic treatments, can increase the risk of spread to adjacent areas. Recurrence is common and does not necessarily indicate treatment failure.1,6,10
Follow-up
Warts commonly require up to 12 weeks of therapy to achieve clinical resolution, especially with non-prescription treatments.2 Without structured follow-up, patients may discontinue treatment prematurely due to slow response, leading to treatment failure or recurrence.
Pharmacists play an important role in the early identification, treatment, education and monitoring of cutaneous warts. By taking a thorough history when patients present with skin concerns, pharmacists can assist with timely intervention, reducing transmission and preventing complications.1
Pharmacists may recommend first-line therapies such as SA and guide patients on correct use to optimise outcomes and minimise adverse effects.
Pharmacists can also provide education and counselling on the viral nature of warts, transmission routes and treatment expectations.
Importantly, pharmacists are positioned to encourage patients to return for follow-up if progress is sub-optimal, allowing ongoing monitoring of adherence, response or the need to refer.1,2,10
Pharmacists must be able to recognise red flags, such as non-resolving lesions, sensitive anatomical locations or immunocompromised status, and refer to GPs for further management.8
An important part of counselling involves explaining the likelihood of wart recurrence and emphasising the role of good hygiene in reducing the risk of infection.1,2,10
Conclusion
Cutaneous warts are common and generally have a favourable prognosis, with many resolving spontaneously within months to years. However, people often seek treatment to improve cosmetic appearance or reduce discomfort.2 Warts may persist, recur or become susceptible to secondary infection if inappropriately treated.1,2,10
Pharmacists play an active role in treatment by identifying warts, advising on treatment, counselling on correct application, and identifying when referral may be required.
Case scenario continuedYou explain to Fernando that the lesion is consistent with a plantar wart and recommend starting a combination salicylic acid and lactic acid preparation with nightly application following debridement. You counsel on application technique, the importance of good hygiene and remaining consistent with treatment. You encourage him to return in 2 weeks for review, and when he presents, you find it is noticeably reduced and no longer painful. You advise him to continue with treatment until it disappears, but not for longer than 12 weeks, and to remain vigilant for signs of infection or recurrence. Fernando is grateful for your help and soon returns to participating in sports. |
Diyar Emadi MBA, BPharm, CredPharm (MMR), CDE, CPT, SCOPE certified, MPS is a credentialed pharmacist and diabetes educator with expertise in insulin pumps, obesity and weight management. Founder of Synergy Medicine Consulting, he works as a consultant pharmacist in general practice and as a diabetes educator alongside endocrinologists in specialist practice. With an MBA and a background spanning community, hospital and pharmaceutical industry roles, Diyar brings clinical and strategic insight to his work as a medical writer.
Sharon Ambalal MPH, BPharm, MPS
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[post_content] => The most-read stories of the year highlight where clinical practice, regulation and professional reform collided.
From sweeping Therapeutic Guidelines updates to unresolved scheduling decisions and award wage reform, these five stories captured pharmacists’ attention and reflected the pressures shaping practice in 2025.
1. Therapeutic Guidelines overhaul UTI treatment
The Therapeutic Guidelines on antibiotics underwent the biggest update in TG history, encompassing 1,400 medicine recommendations to reflect new evidence and rising antimicrobial resistance.
The first stage targeted infections managed in primary care, with one of the most significant shifts made to the management of urinary tract infections (UTIs). Trimethoprim is no longer first-line therapy for uncomplicated cystitis in non-pregnant adults due to resistance in Escherichia coli (E. coli). Instead, nitrofurantoin is now recommended as the preferred first-line option, with fosfomycin and cefalexin listed as alternatives.
This update impacted pharmacists offering UTI treatment services nationwide, particularly in states such as New South Wales – where trimethoprim was previously first-line therapy.
2. Is Rikodeine still being rescheduled?
Last year, the TGA made an interim decision to upschedule dihydrocodeine due to concerns about potential misuse, abuse and dependence. The TGA Delegate’s interim decision was to amend the Pharmacist Only entry for dihydrocodeine to restrict undivided oral liquid preparations to a maximum primary pack size of 100 mL from 1 October 2025.
But the final decision is yet to be published, with a public consultation process causing the delay. In September 2024, the TGA confirmed that final decisions had been deferred while the consultation responses were further considered.
In the meantime, dihydrocodeine scheduling remains unchanged – with pharmacists continuing to field frequent requests for Rikodeine, often from patients without symptoms of dry cough.
3. Hiprex becomes a Pharmacist Only medicine
Methenamine hippurate, sold as Hiprex and Uramet, officially became a Pharmacist Only medicine on 1 October 2025. Previously unscheduled and available as a general sales medicine, the aim of the change was to ensure pharmacist oversight and safer use.
While a Pharmacy Only designation was considered, the TGA concluded this would not prevent inappropriate use among people who have not been medically assessed.
4. What you need to know about the paracetamol regulation changes
From 1 February 2025, paracetamol pack sizes sold in pharmacies changed as part of the TGA’s final decision on paracetamol access controls. Packs containing 50–100 tablets or capsules became Pharmacist Only medicines and general-sale pack sizes reduced from 20 to 16 tablets, among other changes – with the aim of reducing the amount of paracetamol stored in households to prevent harm from intentional overdose.
Each year, around 225 Australians are hospitalised with liver injury due to paracetamol overdose, with the highest rates among adolescents and young adults, particularly females.
Pharmacists should act as ‘champions for the change’, reinforcing safe use and helping to limit surplus paracetamol in homes, said PSA Senior Pharmacist – Strategic Policy, Peter Guthrey MPS at the time.
‘The data on intentional overdose involving paracetamol is alarming … scheduling changes are not the full solution, but are a strategy which could make a positive difference if it changes the patterns of paracetamol supply,’ he said.
5. Fair Work publishes gender undervaluation decision on pharmacist award
In April, the Fair Work Commission’s Expert Panel for pay equity in the care and community sector issued its initial decision on the Gender-based undervaluation – priority awards review, making significant determinations for the Pharmacy Industry Award 2020, under which most community pharmacists are employed.
The Expert Panel found that pharmacists covered by the award have been subject to gender-based undervaluation, with the assessment considering factors such as:
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[post_content] => New year, new policy and practice changes. Here’s what pharmacists will need to navigate from January.
In 2026, pharmacists can expect some changes to education, medicine costs and credentialing standards.
AP has rounded up the key changes pharmacists can expect from 1 January.
1. PBS co‑payment will drop
From 1 January 2026, the maximum Pharmaceutical Benefits Scheme (PBS) co‑payment for general patients will drop from $31.60 to $25.00 per prescription.
This marks a major reduction in out-of-pocket costs for Australians without a concession card, and the first time in more than 20 years that PBS medicines will cost no more than $25.
However, indexation on the general patient co-payment will resume in 2027 in line with the Consumer Price Index (CPI). Although PBS medicines will not be permanently capped at $25, the long‑term trajectory of general patient co‑payments will rise from a much lower baseline.
2. Transition to the new MMR credential must be completed
By 1 January 2026, pharmacists must have transitioned to the APC’s new Medication Management Review credential to continue:
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[post_content] => The Pharmaceutical Society of Australia (PSA) recently launched the PSA Standards for Continuing Professional Development (CPD) for Pharmacists, marking a new era for the accreditation of CPD activities for the pharmacy profession.
The launch of the PSA Standards follows the retirement of the Australian Pharmacy Council (APC) Accreditation Standards for CPD Activities on 31 December 2025. Developed through extensive consultation with the profession, the PSA Standards provide a contemporary framework to guide the quality and educational integrity of continuing professional development activities for pharmacists.
With the commencement of these Standards, CPD providers can apply for accreditation under the PSA Accredited CPD framework.
All supporting materials, including application forms and the PSA Accredited CPD Provider Handbook, will be available on the PSA website from 5 January 2026.
PSA acknowledges and thanks the individuals and organisations who contributed feedback during the consultation process and looks forward to supporting providers in delivering high-quality education for pharmacists.
PSA National President Associate Professor Fei Sim FPS reflected on the process of developing the Standards, acknowledging the work of all involved, including the individuals and organisations who provided feedback during the consultation period.
“The approval of the PSA standards for CPD for pharmacists marks a significant milestone in PSA’s already rich history in upholding quality education standards, now spanning decades,” she said.
“We know our education and continuing professional development are core values for our members. I want to assure you that these standards will give pharmacists the confidence that the CPD they access is of high quality.
“I sincerely thank everyone who participated in the consultation process. It is an incredible achievement to be sharing this news only 5 months after announcing PSA’s intent to publish these education standards.”
To view the Standards or enquire about the accreditation process, please visit https://www.psa.org.au/cpd/
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[post_content] => From early detection to screening and medicine management – pharmacists are increasingly involved in reducing the burden of kidney disease.
Chronic kidney disease (CKD) is a common but often ‘silent’ condition. One in three Australians are at risk of developing progressive CKD resulting from comorbidities such as hypertension, diabetes and cardiovascular disease. And most people are asymptomatic until significant kidney damage has occurred.
Familiarity with patients’ medical history equips pharmacists to act as first identifiers of potential CKD and to suggest Kidney Health Checks – which can find CKD in time to better manage the condition. People with diabetes, hypertension, family history of kidney disease, or those who are over 18 and from an Aboriginal and Torres Strait Islander family should have annual Kidney Health Checks. Current smokers and people with other risk factors, such as cardiovascular disease or obesity, should have Kidney Health Checks every 2 years.
Screening for CKD
A trial of CKD screening by pharmacists is currently underway across Australia, covering nearly 1,500 patients in 192 community pharmacies.
According to the University of Sydney’s Associate Professor Ron Castelino, a practising renal pharmacist at Blacktown Hospital, the trial was inspired by the discrepancy between the routine kidney function test results available to hospital pharmacists – who can then adjust doses of medicines cleared by the kidneys – and the lack of information available to community pharmacists.
The pilot first required pharmacists to assess patients’ likelihood of developing CKD using a series of questions about their risk factors. Around 30% of the patients in the recruitment pool were assessed as having a moderate to severe risk of developing CKD within 5 years. They were offered a point-of-care kidney function test, which is essentially a finger-prick test similar to the glucometer test used to manage diabetes, A/Prof Castelino says.
The point-of-care test provides an immediate reading of the patient’s estimated glomerular filtration rate (eGFR) and levels of serum creatinine to measure how well the kidneys are filtering waste from the blood. Patients identified as having impaired kidney function are referred to their general practitioner (GP) for more comprehensive blood and urine tests, spaced over at least 3 months, to diagnose CKD, he adds.
‘There are two or three benefits that I see straight away with the point-of-care device screening, particularly in rural and remote areas where pharmacy is more accessible,’ A/Prof Castelino says.
‘Patients can walk in and get the finger-prick test as the initial screening. Those who do come up with a decline in kidney function can be referred to the doctor straightaway, so that’s a massive positive. It’s also a good opportunity for pharmacists to see whether the dosage of medicines cleared by the kidneys may need to be adjusted.’
Management in pharmacy
Pharmacists’ therapeutic knowledge puts them in a unique position to help people manage CKD. A recent systematic review and meta-analysis of randomised controlled trials – including adults with a diagnosis of CKD and those with and without kidney replacement therapy – found pharmacist interventions resulted in statistically significant improvements
in systolic blood pressure and haemoglobin levels.5
But the findings showed pharmacist interventions had mixed results for various outcomes, according to the scientists. ‘Future studies should be more robustly designed and take into consideration the role of the pharmacist in prescribing and deprescribing, the findings of which will help inform research and clinical practice,’ they concluded.5
Kidney care for Aboriginal and Torres Strait Islander peoples
Chronic kidney disease is prevalent among Aboriginal and Torres Strait Islander peoples.6 Breonny Robson, Kidney Health Australia’s General Manager, Clinical and Research, says pharmacists should familiarise themselves with the Caring for Australians and New Zealanders with Kidney Impairment (CARI) recommendations for providing culturally safe kidney care in Aboriginal and Torres Strait Islander peoples.7
‘Pharmacists should also ensure pharmacy staff undertake formal cultural safety training and establish that they have referral pathways for First Nations peoples back to their local Aboriginal Community Controlled Health Organisations (ACCHOs) and GP to ensure continuity of care,’ she says.
‘First Nations peoples should be encouraged to have their annual 715 health check [the Medicare number for a comprehensive health check], ensure that they are correctly identified as Aboriginal and/or Torres Strait Islander at the service and that they are correctly enrolled in the Closing the Gap program.’8
Ms Robson adds that pharmacists should discuss potential point-of-care testing and in-pharmacy screening with the local ACCHO, so that community members are linked to their regular health service for continuity of care.
Pharmacists supporting CKD treatment
CKD usually entails ‘super-polypharmacy’.9 With patients often managing 16–20 medicines, pharmacists have a vital role to play in medicines review, dose adjustment and transplant support.
Hanh Tran, Senior Pharmacist (Renal) at Royal Adelaide Hospital, says polypharmacy is a significant challenge in CKD due to patients’ unstable renal function, their frequent medicines changes, and the involvement of multiple specialists (including endocrinologists, cardiologists and GPs).
‘Patients often experience “pill burden” and contradictory advice,’ she says. ‘A classic example is calcium: commonly prescribed as a phosphate binder in CKD, it must be taken with food to bind dietary phosphate – which is contrary to the usual advice for calcium supplementation.’
Renal dosing principles include maintaining medicine records, providing patients with updated lists of medicines, and ensuring they are equipped to manage complex medicines regimens.
Ms Tran says that dosing advice should be provided to relevant healthcare providers, including doctors, nurses and nurse practitioners.
Meanwhile, people living with CKD in rural and regional areas may have limited access to nephrology services or dialysis centres.10 Gauri Godbole FPS, a specialist aged care pharmacist at Gosford Hospital, says that in cases of patients with advanced CKD requiring polypharmacy, it’s important to ‘prioritise medicines with clear evidence of benefit that are aligned to patient goals, and ensure renal-appropriate dosing’.
Identifying the patient’s best possible medication history, including the over-the-counter and herbal products they take, is the first step, she says. Ms Godbole then identifies the high-risk or nephrotoxic medicines and recommends dose adjustments or, in certain cases, discontinuation, based on renal function and clinical benefit.
‘Goals of care often evolve over time, serving as an important catalyst for deprescribing,’ she says.
‘We identify nephrotoxic, duplicate or low-value medicines for deprescribing, especially where benefits are limited in advanced illness. Tools such as STOPP/START, STOPPFrail and STOPPCog, alongside multidisciplinary input and shared decision-making, support tailored recommendations. Deprescribing should be monitored with regular follow-up, symptom checks, and tapering if needed.’
The Australian Pharmaceutical Formulary and Handbook (APF) supports the concept of deprescribing in patients with progressive CKD where the benefit of long-term preventive medicines (such as statins in the elderly) may no longer outweigh the risks. Deprescribing should also be considered for medicines with narrow therapeutic windows or renal toxicity such as lithium, NSAIDs, metformin and SGLT2 inhibitors (depending on eGFR).11
The APF recommends assessing kidney function before adjusting dosages and referencing renal dosing guides when determining dose changes. It also recommends avoiding or reducing the dosage of nephrotoxic drugs such as NSAIDs and aminoglycosides, and advises special caution with drugs cleared renally – including metformin (which carries a risk of lactic acidosis), digoxin and DOACs (such as apixaban).11
Providing transplant support
Community pharmacists can provide essential support for kidney transplant recipients in regional, rural and remote areas of Australia.12 Renal transplant pharmacists in hospitals play a vital role within the transplant team, supporting recipients throughout their journey from surgery to long-term post-transplant care, with a strong focus on medicine management, Ms Tran says.
Renal hospital pharmacists are available in both inpatient and outpatient settings to answer patients’ questions, troubleshoot issues related to specialised medicines and provide guidance on new therapies, she adds. They provide support to ensure changes in medicines are made safely and are tailored to each patient’s needs. Renal pharmacists can also provide the patient with information about kidney medicines and initiate suitable and tailored support.
This can be done in inpatient wards, outpatient clinics and via telehealth, with renal pharmacists able to help relieve CKD symptoms such as water retention, swelling, common uraemic symptoms (itchiness, muscle cramps, fatigue and weakness, ongoing nausea and poor appetite, deterioration in memory), and chronic neuropathic pain.
At bigger hospitals, renal pharmacists work with dialysis units to ensure renal medicines such as erythropoietin injections, dialysis-related blood thinners and iron infusions are appropriately supplied and used safely, Ms Tran adds.
‘Patients who are new to dialysis receive a comprehensive medication review to ensure their current medicines are still suitable for dialysis,’ she says.
‘Patients receive thorough education about how and why some medicines would be dialysed or interact with dialysis, and how and why blood and antidiabetic medication requirements could significantly change when a patient is undergoing dialysis.’
Trials have found that optimal medicine use can significantly reduce the risk of kidney failure while also contributing to the delay or prevention of dialysis.
‘SGLT2 inhibitors can significantly slow the progression of CKD and reduce the risk of needing dialysis in patients with and without type 2 diabetes,’ a meta-analysis research paper concluded. ‘These effects were shown consistently across groups with varying baseline eGFR values.’ 13
The future of pharmacy care
As the medicines experts in the healthcare team, pharmacists are essential for ensuring safe and effective pharmacotherapy in kidney disease patients, Ms Robson says.
‘Besides the traditional roles of verifying dose accuracy and reviewing drug interactions, pharmacists can recommend treatments – such as ACE inhibitors and SGLT2 inhibitors – that have been shown to slow the progression of kidney disease,’ she says.
Pharmacists can also offer self-management counselling, review the potential symptoms of worsening kidney function, provide advice on adverse effects from medicines, and assist with strategies for medicine adherence, she adds.
‘At Kidney Health Australia, we welcome any initiative that will improve outcomes for people living with kidney disease – it is absolutely necessary that we place greater focus on the early detection, diagnosis and management of CKD, and pharmacists are well placed to do this,’ Ms Robson says.
‘Kidney Health Australia has recently partnered with the Pharmaceutical Society of
Australia to deliver educational programs to primary care providers and pharmacists in the community, stressing the need for at-risk patients to get a Kidney Health Check.’
Patient care and screening initiatives in community pharmacy, she adds, will allow pharmacists to play a key role in supporting Kidney Health Australia’s goal of ending
dialysis by 2050.
References
- Kidney Health Australia. Symptoms of kidney disease. At: https://kidney.org.au/your-kidneys/what-is-kidney-disease/symptoms-of-kidney-disease
- National Kidney Foundation. Pharmacists and chronic kidney disease. At: https://www.kidney.org/professionals/ckdintercept/pharmacists-and-chronic-kidney-disease
- Kidney Health Australia. Kidney health check. At: https://kidney.org.au/your-kidneys/know-your-kidneys/know-the-risk-factors/kidney-health-check
- Tesfaye W, Krass I, Sud K, Johnson DW, Van C, Versace VL, et al. Impact of a pharmacy-led screening and intervention in people at risk of or living with chronic kidney disease in a primary care setting: a cluster randomised trial protocol. BMJ Open. 2023;13(12):e079110. At: https://bmjopen.bmj.com/content/13/12/e079110. BMJ Open
- Ardavani A, Curtis F, Hopwood E, et al. Effect of pharmacist interventions in chronic kidney disease: a meta-analysis. Nephrol Dial Transplant. 2025;40(5):884–907. At: https://academic.oup.com/ndt/article/40/5/884/7816383
- Australian Indigenous HealthInfoNet. Latest information and statistics on kidney health. At: https://healthinfonet.ecu.edu.au/learn/health-topics/kidney/latest-information-and-statistics-on-kidney-health/
- CARI Guidelines. First Nations Australian guidelines. At: https://www.cariguidelines.org/first-nations-australian-guidelines/
- Closing the Gap. At: https://www.closingthegap.gov.au
- Oosting IJ, Colombijn JMT, Kaasenbrood L, Liabeuf S, Laville SM, Hooft L, et al. Polypharmacy in patients with CKD: a systematic review and meta-analysis. Kidney360. 2024;5(6):841–850. At: https://pubmed.ncbi.nlm.nih.gov/38661553/. ScienceDirect+1
- Wright J, Glenister KM, Thwaites R, Terry D. The importance of adequate referrals for chronic kidney disease management in a regional Australian area of nephrologist workforce shortage. Aust J Gen Pract. 2018;47(1–2):58–62. At: https://www1.racgp.org.au/ajgp/2018/january-february/the-importance-of-adequate-referrals-for-chronic-k
- Pharmaceutical Society of Australia. Australian Pharmaceutical Formulary. At: https://www.psa.org.au/media-publications/australian-pharmaceutical-formulary/
- Watters TK, Scholes-Robertson NJ, Mallett AJ, Glass BD. Exploring the pharmacist's role in regional, rural, and remote kidney transplant care: Perspectives of health professionals and transplant recipients. Explor Res Clin Soc Pharm. 2025;18:100587. doi:10.1016/j.rcsop.2025.100587. PMID: 40177655; PMCID: PMC11964747
- Mahendra AI, Samsu N, Gunawan A, Rifai A. SGLT-2 inhibitors delay kidney failure progression and reduce need of dialysis in chronic kidney disease patients: a meta-analysis. Nephrol Dial Transplant. 2023;38(Supplement_1):gfad063c_2934. At: https://academic.oup.com/ndt/article/38/Supplement_1/gfad063c_2934/7196059
[post_title] => Finding the missing millions with CKD
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[post_content] => Case scenario
Fernando, a 16-year-old student, walks into your pharmacy concerned about a rough, painful lesion on the bottom of his foot. He informs you that he has been picking at it, as it has been bothering him, to the point that he is now limping and avoiding sports (football and swimming). He has not tried any treatments, but he has ‘Googled’ it.
On examination, you notice a thickened and tender lesion with black dots on the surface. He is not taking any regular medicines and is otherwise healthy.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
A cutaneous wart is a common, viral skin growth caused by the human papillomavirus (HPV). They are typically classified based on their location on the body and their structure.1 Warts are generally classified as1,2:
Most warts are harmless. Without active treatment, warts will disappear on their own within months to years.1,2 Occasionally, warts can cause discomfort, cosmetic concern or cause temporary functional impairment (e.g. plantar warts).2 Once active treatment is started, persistence is key to ensuring optimal eradication.2
Cutaneous warts are common, particularly among children, adolescents, and individuals who are immunocompromised. Globally, the prevalence of cutaneous warts varies between 7% and 12% in the general population, with the highest rates reported among school-aged children (10–20%).3
In Australia, the most frequently observed types of cutaneous warts are common warts (verruca vulgaris) on hands and knees, and plantar warts (verruca plantaris) on the soles of the feet.2 Studies have found that approximately one-quarter (24%) of school children have had at least one wart, with a significantly higher prevalence observed among those who swim regularly or share footwear.4
Warts are caused by infection with specific types of HPV, of which more than 200 genotypes have been identified.3 Of those, types 1, 2, 4, 27 and 57 are most commonly associated with cutaneous warts.1,3 HPV is transmitted via direct contact with infected skin or indirectly through contaminated environments (e.g. communal showers, swimming pool decks, or gym mats).1–3 HPV can survive for days on surfaces, facilitating indirect spread.6
Once HPV breaches the skin barrier, it infects basal keratinocytes within the epidermis. The virus then induces proliferation of keratinocytes without inducing cell lysis or triggering a significant immune response, thereby evading immune detection.6 As infected cells differentiate and migrate toward the skin surface, viral replication continues, giving rise to the following characteristic histopathological changes that produce the rough, raised appearance of warts5:
Since viral activity remains confined to the epidermis and does not invade deeper tissues, the lesions are typically benign.6
Several factors influence susceptibility to cutaneous warts.
Age
Cutaneous warts are frequently observed in children and adolescents.1 Prevalence tends to decline in adulthood.7
Skin trauma
Cuts, abrasions or frequent friction facilitate viral entry by disrupting the skin barrier, thereby increasing susceptibility.1,2
Immunosuppression
Individuals who are immunocompromised (e.g. those with HIV infection), recipients of organ transplants, or patients receiving immunosuppressive therapy are more prone to persistent and treatment-resistant warts.1
Occupational or recreational exposure
Certain individuals are placed at increased risk due to their environment, such as butchers (susceptible to abrasions, cuts), swimmers (prolonged exposure to moist, communal environments) and athletes (increased skin to skin transmission in contact sports and shared equipment). Overall risk is generally increased with close contact and communal environments, although evidence varies among studies.3
Poor skin hygiene and occlusion
Excess moisture and skin maceration compromise the integrity of the epidermis, creating favourable conditions for infection. 2,3
Atopic dermatitis
A compromised skin barrier may increase susceptibility.1,5
Warts typically have the following presentation5:
Warts range in size from a few millimetres to over a centimetre in diameter and characteristically disrupt normal skin lines.5 They may occur as solitary lesions or in clusters, sometimes coalescing into plaques, particularly in immunocompromised individuals.8
Table 1 summarises the distinguishing features that differentiates subtypes.
Symptoms
Most cutaneous warts are asymptomatic, but they may cause pain, itching or tenderness, especially when located on pressure points like the feet or periungual areas.5,6 Cosmetic distress and social embarrassment are common, particularly for visible or facial warts.8
Diagnosis
Cutaneous warts are diagnosed clinically, based on their appearance, location and patient history.1,3,8 Several skin conditions may resemble the appearance of cutaneous warts5,8:
A thorough patient history, lesion inspection, and understanding of risk factors can aid in distinguishing benign warts from conditions that may require further investigation or treatment.3
Prognosis
The prognosis for cutaneous warts is generally favourable, with most cases being self-limiting. Spontaneous resolution occurs in 50–70% of cases within 2 years, particularly in children and adolescents.4,5
The likelihood of resolution depends on several factors, including patient age, immune status and lesion characteristics.8 Younger patients typically experience higher clearance rates, while those who are immunocompromised may develop more extensive and persistent disease.1 Warts located on plantar or periungual sites, as well as larger lesions, tend to be more resistant to resolution.6
Even without treatment, the immune system can eventually clear the virus.2 However, recurrence is possible, and reinfection may occur via autoinoculation (self-spread from one site on the body to another) or contact with contaminated surfaces.2
The primary aim of treatment for cutaneous warts is to stimulate a host immune response against HPV, often by inducing irritation or inflammation within the lesion.10 By doing so, the following can be achieved3,6,10:
Importantly, patients should be educated that no treatment guarantees 100% success, and that multiple treatment sessions and sustained compliance may be required. Notably, one-third of warts resolve spontaneously within 3 months and two–thirds resolve in 2 years.5,9
Management should be individualised, considering the patient’s age, immune status, wart type, number, location, duration and impact on quality of life.5
Monitoring
In children or patients with recent-onset warts that are not painful or distressing, simply waiting and monitoring is a reasonable option.5,8 This approach may be preferred in young children where treatments may cause discomfort.
Salicylic acid
Salicylic acid (SA) at a concentration of 15–40% is considered the first-line pharmacological treatment for most cutaneous warts.5,9 As a keratolytic agent, it works by softening and progressively removing hyperkeratotic tissue.9 Treatment involves daily application, often for up to 12 weeks.9,10 Evidence indicates that efficacy of SA is improved when the wart is soaked in warm water for 5–10 minutes followed by mechanical debridement, such as paring or filing the lesion prior to application, as this improves penetration of SA into affected tissue.2,10
SA preparations available in community pharmacy include solutions, paints, sticks and pens that are applied daily,9 and medicated discs that are typically left on for 48 hours and repeated for up to 12 weeks as required.7,8
Evidence for the use of SA as a first-line option has shown a cure rate of up to 75% when compared to placebo.9
Adverse effects such as local irritation, blistering or pain are common following SA application.2 Covering the wart with occlusive tape after applying SA helps to prevent contact with healthy skin.10
Salicylic acid with lactic acid and podophyllum resin
Lactic acid is a keratolytic agent that softens and breaks down the thickened skin of warts, helping them shed more easily. It is often combined with SA in topical treatments to enhance removal and promote healthy skin regeneration.10
Podophyllum resin is available in some OTC products and is typically combined with salicylic and lactic acids to treat stubborn common warts. Its active compound, podophyllotoxin, arrests cell division and destroys wart tissue.2,8 Because systemic absorption can cause toxicity, products are applied sparingly to intact skin and avoided in pregnancy or on large or inflamed areas. 2,9 Higher-strength podophyllotoxin for anogenital warts is Schedule 4 (Prescription Only).2
Cryotherapy
Cryotherapy is a second-line option for adults or older children with painful, persistent, or cosmetically concerning warts.9 Cryotherapy with liquid nitrogen (through a medical practitioner) or dimethyl ether and propane (DMEP), a non-prescription product, induces tissue necrosis through freezing.8,9 Non-prescription DMEP products are colder than ambient but do not reach liquid nitrogen temperatures and are typically less effective.10
Cryotherapy is usually administered at intervals of 2–3 weeks for up to 12 weeks, with multiple sessions often required for optimal clearance.9 The procedure can be painful, so its use is typically avoided in young children.9
Adverse effects include pain, blistering and pigmentation changes. Its efficacy is comparable to SA when compliance to therapy is high.3,9
Alternative or specialist treatment
In cases where first- and second-line therapy fails, patients may be referred for specialist treatments. Options include immunotherapy (e.g. topical imiquimod), intralesional antigen injections, as well as procedural approaches, such as laser therapy or electrosurgery.3,8,9
Imiquimod stimulates local immune responses and may be used off-label for cutaneous warts, particularly recalcitrant (resistant to treatment) or widespread cases.5,8,9 While evidence is limited for non-genital warts, it remains an option for referral or specialist use.9
Laser therapy, curettage and surgical excision are typically reserved for warts not responding to conservative measures.3 These options carry risks such as scarring and are performed in specialist settings.2,9
Referral should be considered for immunocompromised patients, for lesions with features suggestive of skin cancer, in cases of extensive or treatment-resistant warts, and bleeding or rapidly growing lesions.9
Other therapies
Occlusion – duct tape
Occlusion with duct tape is a low-cost method that involves covering the wart with duct tape and changing it weekly with periodic debridement.9 Although evidence is mixed,9 it is a well-tolerated adjunct or alternative in paediatric cases, or for patients preferring non-chemical options.8 Patient expectations should be modest.9
Zinc
Oral and topical zinc have been studied in wart treatment due to their immunomodulatory properties.9 Oral zinc has been shown to be effective at treating recalcitrant warts when administered at therapeutic doses.8 However, evidence is limited, and results across studies have been mixed. 8 Its role in routine management remains uncertain.9
Treatment considerations
Treatment of cutaneous warts requires persistence.3 Many patients may discontinue therapy prematurely, often due to perceived lack of efficacy, highlighting the importance of counselling around expected treatment duration.1-3
Adverse effects such as local irritation, blistering, or pain are common.1 Inappropriately applied SA or cryotherapy can damage surrounding skin, spread the virus or lead to secondary infection.10 The use of petroleum jelly around the lesion or tape over the lesion is recommended to protect surrounding healthy skin.10
Other skin conditions can mimic the presentation of cutaneous warts, thereby requiring alternative management. Lesions that bleed, ulcerate or change in appearance should also prompt further assessment.
Precautions
Children, people with diabetes and those who are immunocompromised may present as more complicated cases or have contraindications to standard therapy.8,9 Avoid the use of keratolytic agents and aggressive debridement in patients with diabetes or peripheral vascular disease, as acute inflammation and ulceration may occur.2 Plantar warts in people with diabetes require cautious management, as neuropathy and impaired circulation increase the risk of ulceration, secondary infection and delayed wound healing.6 Alternative treatments or referral to a GP or dermatologist may be required.
Children are more sensitive to irritation and systemic absorption of active ingredient, therefore keratolytic agents should be used with caution. However, SA can be used in children with careful application and skin protection, avoiding large areas or irritated skin.2
Complications
Secondary infection
Warts that are irritated by scratching, shaving or treatment can become infected. The need for good hygiene practices and protecting the lesion site is important.6 Educate patients about signs of infection, such as4–6:
Patients should be advised to withhold treatment and refer to a GP if signs of infection are present.
Pain and irritation
Plantar warts may become painful due to pressure while walking.6 The use of keratolytics and cryotherapy can result in additional pain.
To prevent discontinuation of treatment, cushioning for plantar warts (e.g. with felt pads) may be recommended to alleviate discomfort,6 or advise patients on appropriate analgesia if needed.
Overuse or misapplication of topical treatments can cause irritant contact dermatitis or chemical burns. Precise application and protective measures can minimise irritation.10 Treatments for warts can potentially lead to scarring.10
Spread and recurrence
Immunosuppression8 and local trauma, especially when adjacent healthy skin is accidentally pared prior to application of keratolytic treatments, can increase the risk of spread to adjacent areas. Recurrence is common and does not necessarily indicate treatment failure.1,6,10
Follow-up
Warts commonly require up to 12 weeks of therapy to achieve clinical resolution, especially with non-prescription treatments.2 Without structured follow-up, patients may discontinue treatment prematurely due to slow response, leading to treatment failure or recurrence.
Pharmacists play an important role in the early identification, treatment, education and monitoring of cutaneous warts. By taking a thorough history when patients present with skin concerns, pharmacists can assist with timely intervention, reducing transmission and preventing complications.1
Pharmacists may recommend first-line therapies such as SA and guide patients on correct use to optimise outcomes and minimise adverse effects.
Pharmacists can also provide education and counselling on the viral nature of warts, transmission routes and treatment expectations.
Importantly, pharmacists are positioned to encourage patients to return for follow-up if progress is sub-optimal, allowing ongoing monitoring of adherence, response or the need to refer.1,2,10
Pharmacists must be able to recognise red flags, such as non-resolving lesions, sensitive anatomical locations or immunocompromised status, and refer to GPs for further management.8
An important part of counselling involves explaining the likelihood of wart recurrence and emphasising the role of good hygiene in reducing the risk of infection.1,2,10
Conclusion
Cutaneous warts are common and generally have a favourable prognosis, with many resolving spontaneously within months to years. However, people often seek treatment to improve cosmetic appearance or reduce discomfort.2 Warts may persist, recur or become susceptible to secondary infection if inappropriately treated.1,2,10
Pharmacists play an active role in treatment by identifying warts, advising on treatment, counselling on correct application, and identifying when referral may be required.
Case scenario continuedYou explain to Fernando that the lesion is consistent with a plantar wart and recommend starting a combination salicylic acid and lactic acid preparation with nightly application following debridement. You counsel on application technique, the importance of good hygiene and remaining consistent with treatment. You encourage him to return in 2 weeks for review, and when he presents, you find it is noticeably reduced and no longer painful. You advise him to continue with treatment until it disappears, but not for longer than 12 weeks, and to remain vigilant for signs of infection or recurrence. Fernando is grateful for your help and soon returns to participating in sports. |
Diyar Emadi MBA, BPharm, CredPharm (MMR), CDE, CPT, SCOPE certified, MPS is a credentialed pharmacist and diabetes educator with expertise in insulin pumps, obesity and weight management. Founder of Synergy Medicine Consulting, he works as a consultant pharmacist in general practice and as a diabetes educator alongside endocrinologists in specialist practice. With an MBA and a background spanning community, hospital and pharmaceutical industry roles, Diyar brings clinical and strategic insight to his work as a medical writer.
Sharon Ambalal MPH, BPharm, MPS
[post_title] => Cutaneous warts in community practice [post_excerpt] => Pharmacists play an important role in the early identification, treatment, education and monitoring of cutaneous warts. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => cutaneous-warts-in-community-practice [to_ping] => [pinged] => [post_modified] => 2025-12-17 17:00:00 [post_modified_gmt] => 2025-12-17 06:00:00 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=30883 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Cutaneous warts in community practice [title] => Cutaneous warts in community practice [href] => https://www.australianpharmacist.com.au/cutaneous-warts-in-community-practice/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 31108 [authorType] => )td_module_mega_menu Object
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[post_content] => The most-read stories of the year highlight where clinical practice, regulation and professional reform collided.
From sweeping Therapeutic Guidelines updates to unresolved scheduling decisions and award wage reform, these five stories captured pharmacists’ attention and reflected the pressures shaping practice in 2025.
1. Therapeutic Guidelines overhaul UTI treatment
The Therapeutic Guidelines on antibiotics underwent the biggest update in TG history, encompassing 1,400 medicine recommendations to reflect new evidence and rising antimicrobial resistance.
The first stage targeted infections managed in primary care, with one of the most significant shifts made to the management of urinary tract infections (UTIs). Trimethoprim is no longer first-line therapy for uncomplicated cystitis in non-pregnant adults due to resistance in Escherichia coli (E. coli). Instead, nitrofurantoin is now recommended as the preferred first-line option, with fosfomycin and cefalexin listed as alternatives.
This update impacted pharmacists offering UTI treatment services nationwide, particularly in states such as New South Wales – where trimethoprim was previously first-line therapy.
2. Is Rikodeine still being rescheduled?
Last year, the TGA made an interim decision to upschedule dihydrocodeine due to concerns about potential misuse, abuse and dependence. The TGA Delegate’s interim decision was to amend the Pharmacist Only entry for dihydrocodeine to restrict undivided oral liquid preparations to a maximum primary pack size of 100 mL from 1 October 2025.
But the final decision is yet to be published, with a public consultation process causing the delay. In September 2024, the TGA confirmed that final decisions had been deferred while the consultation responses were further considered.
In the meantime, dihydrocodeine scheduling remains unchanged – with pharmacists continuing to field frequent requests for Rikodeine, often from patients without symptoms of dry cough.
3. Hiprex becomes a Pharmacist Only medicine
Methenamine hippurate, sold as Hiprex and Uramet, officially became a Pharmacist Only medicine on 1 October 2025. Previously unscheduled and available as a general sales medicine, the aim of the change was to ensure pharmacist oversight and safer use.
While a Pharmacy Only designation was considered, the TGA concluded this would not prevent inappropriate use among people who have not been medically assessed.
4. What you need to know about the paracetamol regulation changes
From 1 February 2025, paracetamol pack sizes sold in pharmacies changed as part of the TGA’s final decision on paracetamol access controls. Packs containing 50–100 tablets or capsules became Pharmacist Only medicines and general-sale pack sizes reduced from 20 to 16 tablets, among other changes – with the aim of reducing the amount of paracetamol stored in households to prevent harm from intentional overdose.
Each year, around 225 Australians are hospitalised with liver injury due to paracetamol overdose, with the highest rates among adolescents and young adults, particularly females.
Pharmacists should act as ‘champions for the change’, reinforcing safe use and helping to limit surplus paracetamol in homes, said PSA Senior Pharmacist – Strategic Policy, Peter Guthrey MPS at the time.
‘The data on intentional overdose involving paracetamol is alarming … scheduling changes are not the full solution, but are a strategy which could make a positive difference if it changes the patterns of paracetamol supply,’ he said.
5. Fair Work publishes gender undervaluation decision on pharmacist award
In April, the Fair Work Commission’s Expert Panel for pay equity in the care and community sector issued its initial decision on the Gender-based undervaluation – priority awards review, making significant determinations for the Pharmacy Industry Award 2020, under which most community pharmacists are employed.
The Expert Panel found that pharmacists covered by the award have been subject to gender-based undervaluation, with the assessment considering factors such as:
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[post_content] => New year, new policy and practice changes. Here’s what pharmacists will need to navigate from January.
In 2026, pharmacists can expect some changes to education, medicine costs and credentialing standards.
AP has rounded up the key changes pharmacists can expect from 1 January.
1. PBS co‑payment will drop
From 1 January 2026, the maximum Pharmaceutical Benefits Scheme (PBS) co‑payment for general patients will drop from $31.60 to $25.00 per prescription.
This marks a major reduction in out-of-pocket costs for Australians without a concession card, and the first time in more than 20 years that PBS medicines will cost no more than $25.
However, indexation on the general patient co-payment will resume in 2027 in line with the Consumer Price Index (CPI). Although PBS medicines will not be permanently capped at $25, the long‑term trajectory of general patient co‑payments will rise from a much lower baseline.
2. Transition to the new MMR credential must be completed
By 1 January 2026, pharmacists must have transitioned to the APC’s new Medication Management Review credential to continue:
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[post_content] => The Pharmaceutical Society of Australia (PSA) recently launched the PSA Standards for Continuing Professional Development (CPD) for Pharmacists, marking a new era for the accreditation of CPD activities for the pharmacy profession.
The launch of the PSA Standards follows the retirement of the Australian Pharmacy Council (APC) Accreditation Standards for CPD Activities on 31 December 2025. Developed through extensive consultation with the profession, the PSA Standards provide a contemporary framework to guide the quality and educational integrity of continuing professional development activities for pharmacists.
With the commencement of these Standards, CPD providers can apply for accreditation under the PSA Accredited CPD framework.
All supporting materials, including application forms and the PSA Accredited CPD Provider Handbook, will be available on the PSA website from 5 January 2026.
PSA acknowledges and thanks the individuals and organisations who contributed feedback during the consultation process and looks forward to supporting providers in delivering high-quality education for pharmacists.
PSA National President Associate Professor Fei Sim FPS reflected on the process of developing the Standards, acknowledging the work of all involved, including the individuals and organisations who provided feedback during the consultation period.
“The approval of the PSA standards for CPD for pharmacists marks a significant milestone in PSA’s already rich history in upholding quality education standards, now spanning decades,” she said.
“We know our education and continuing professional development are core values for our members. I want to assure you that these standards will give pharmacists the confidence that the CPD they access is of high quality.
“I sincerely thank everyone who participated in the consultation process. It is an incredible achievement to be sharing this news only 5 months after announcing PSA’s intent to publish these education standards.”
To view the Standards or enquire about the accreditation process, please visit https://www.psa.org.au/cpd/
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[post_content] => From early detection to screening and medicine management – pharmacists are increasingly involved in reducing the burden of kidney disease.
Chronic kidney disease (CKD) is a common but often ‘silent’ condition. One in three Australians are at risk of developing progressive CKD resulting from comorbidities such as hypertension, diabetes and cardiovascular disease. And most people are asymptomatic until significant kidney damage has occurred.
Familiarity with patients’ medical history equips pharmacists to act as first identifiers of potential CKD and to suggest Kidney Health Checks – which can find CKD in time to better manage the condition. People with diabetes, hypertension, family history of kidney disease, or those who are over 18 and from an Aboriginal and Torres Strait Islander family should have annual Kidney Health Checks. Current smokers and people with other risk factors, such as cardiovascular disease or obesity, should have Kidney Health Checks every 2 years.
Screening for CKD
A trial of CKD screening by pharmacists is currently underway across Australia, covering nearly 1,500 patients in 192 community pharmacies.
According to the University of Sydney’s Associate Professor Ron Castelino, a practising renal pharmacist at Blacktown Hospital, the trial was inspired by the discrepancy between the routine kidney function test results available to hospital pharmacists – who can then adjust doses of medicines cleared by the kidneys – and the lack of information available to community pharmacists.
The pilot first required pharmacists to assess patients’ likelihood of developing CKD using a series of questions about their risk factors. Around 30% of the patients in the recruitment pool were assessed as having a moderate to severe risk of developing CKD within 5 years. They were offered a point-of-care kidney function test, which is essentially a finger-prick test similar to the glucometer test used to manage diabetes, A/Prof Castelino says.
The point-of-care test provides an immediate reading of the patient’s estimated glomerular filtration rate (eGFR) and levels of serum creatinine to measure how well the kidneys are filtering waste from the blood. Patients identified as having impaired kidney function are referred to their general practitioner (GP) for more comprehensive blood and urine tests, spaced over at least 3 months, to diagnose CKD, he adds.
‘There are two or three benefits that I see straight away with the point-of-care device screening, particularly in rural and remote areas where pharmacy is more accessible,’ A/Prof Castelino says.
‘Patients can walk in and get the finger-prick test as the initial screening. Those who do come up with a decline in kidney function can be referred to the doctor straightaway, so that’s a massive positive. It’s also a good opportunity for pharmacists to see whether the dosage of medicines cleared by the kidneys may need to be adjusted.’
Management in pharmacy
Pharmacists’ therapeutic knowledge puts them in a unique position to help people manage CKD. A recent systematic review and meta-analysis of randomised controlled trials – including adults with a diagnosis of CKD and those with and without kidney replacement therapy – found pharmacist interventions resulted in statistically significant improvements
in systolic blood pressure and haemoglobin levels.5
But the findings showed pharmacist interventions had mixed results for various outcomes, according to the scientists. ‘Future studies should be more robustly designed and take into consideration the role of the pharmacist in prescribing and deprescribing, the findings of which will help inform research and clinical practice,’ they concluded.5
Kidney care for Aboriginal and Torres Strait Islander peoples
Chronic kidney disease is prevalent among Aboriginal and Torres Strait Islander peoples.6 Breonny Robson, Kidney Health Australia’s General Manager, Clinical and Research, says pharmacists should familiarise themselves with the Caring for Australians and New Zealanders with Kidney Impairment (CARI) recommendations for providing culturally safe kidney care in Aboriginal and Torres Strait Islander peoples.7
‘Pharmacists should also ensure pharmacy staff undertake formal cultural safety training and establish that they have referral pathways for First Nations peoples back to their local Aboriginal Community Controlled Health Organisations (ACCHOs) and GP to ensure continuity of care,’ she says.
‘First Nations peoples should be encouraged to have their annual 715 health check [the Medicare number for a comprehensive health check], ensure that they are correctly identified as Aboriginal and/or Torres Strait Islander at the service and that they are correctly enrolled in the Closing the Gap program.’8
Ms Robson adds that pharmacists should discuss potential point-of-care testing and in-pharmacy screening with the local ACCHO, so that community members are linked to their regular health service for continuity of care.
Pharmacists supporting CKD treatment
CKD usually entails ‘super-polypharmacy’.9 With patients often managing 16–20 medicines, pharmacists have a vital role to play in medicines review, dose adjustment and transplant support.
Hanh Tran, Senior Pharmacist (Renal) at Royal Adelaide Hospital, says polypharmacy is a significant challenge in CKD due to patients’ unstable renal function, their frequent medicines changes, and the involvement of multiple specialists (including endocrinologists, cardiologists and GPs).
‘Patients often experience “pill burden” and contradictory advice,’ she says. ‘A classic example is calcium: commonly prescribed as a phosphate binder in CKD, it must be taken with food to bind dietary phosphate – which is contrary to the usual advice for calcium supplementation.’
Renal dosing principles include maintaining medicine records, providing patients with updated lists of medicines, and ensuring they are equipped to manage complex medicines regimens.
Ms Tran says that dosing advice should be provided to relevant healthcare providers, including doctors, nurses and nurse practitioners.
Meanwhile, people living with CKD in rural and regional areas may have limited access to nephrology services or dialysis centres.10 Gauri Godbole FPS, a specialist aged care pharmacist at Gosford Hospital, says that in cases of patients with advanced CKD requiring polypharmacy, it’s important to ‘prioritise medicines with clear evidence of benefit that are aligned to patient goals, and ensure renal-appropriate dosing’.
Identifying the patient’s best possible medication history, including the over-the-counter and herbal products they take, is the first step, she says. Ms Godbole then identifies the high-risk or nephrotoxic medicines and recommends dose adjustments or, in certain cases, discontinuation, based on renal function and clinical benefit.
‘Goals of care often evolve over time, serving as an important catalyst for deprescribing,’ she says.
‘We identify nephrotoxic, duplicate or low-value medicines for deprescribing, especially where benefits are limited in advanced illness. Tools such as STOPP/START, STOPPFrail and STOPPCog, alongside multidisciplinary input and shared decision-making, support tailored recommendations. Deprescribing should be monitored with regular follow-up, symptom checks, and tapering if needed.’
The Australian Pharmaceutical Formulary and Handbook (APF) supports the concept of deprescribing in patients with progressive CKD where the benefit of long-term preventive medicines (such as statins in the elderly) may no longer outweigh the risks. Deprescribing should also be considered for medicines with narrow therapeutic windows or renal toxicity such as lithium, NSAIDs, metformin and SGLT2 inhibitors (depending on eGFR).11
The APF recommends assessing kidney function before adjusting dosages and referencing renal dosing guides when determining dose changes. It also recommends avoiding or reducing the dosage of nephrotoxic drugs such as NSAIDs and aminoglycosides, and advises special caution with drugs cleared renally – including metformin (which carries a risk of lactic acidosis), digoxin and DOACs (such as apixaban).11
Providing transplant support
Community pharmacists can provide essential support for kidney transplant recipients in regional, rural and remote areas of Australia.12 Renal transplant pharmacists in hospitals play a vital role within the transplant team, supporting recipients throughout their journey from surgery to long-term post-transplant care, with a strong focus on medicine management, Ms Tran says.
Renal hospital pharmacists are available in both inpatient and outpatient settings to answer patients’ questions, troubleshoot issues related to specialised medicines and provide guidance on new therapies, she adds. They provide support to ensure changes in medicines are made safely and are tailored to each patient’s needs. Renal pharmacists can also provide the patient with information about kidney medicines and initiate suitable and tailored support.
This can be done in inpatient wards, outpatient clinics and via telehealth, with renal pharmacists able to help relieve CKD symptoms such as water retention, swelling, common uraemic symptoms (itchiness, muscle cramps, fatigue and weakness, ongoing nausea and poor appetite, deterioration in memory), and chronic neuropathic pain.
At bigger hospitals, renal pharmacists work with dialysis units to ensure renal medicines such as erythropoietin injections, dialysis-related blood thinners and iron infusions are appropriately supplied and used safely, Ms Tran adds.
‘Patients who are new to dialysis receive a comprehensive medication review to ensure their current medicines are still suitable for dialysis,’ she says.
‘Patients receive thorough education about how and why some medicines would be dialysed or interact with dialysis, and how and why blood and antidiabetic medication requirements could significantly change when a patient is undergoing dialysis.’
Trials have found that optimal medicine use can significantly reduce the risk of kidney failure while also contributing to the delay or prevention of dialysis.
‘SGLT2 inhibitors can significantly slow the progression of CKD and reduce the risk of needing dialysis in patients with and without type 2 diabetes,’ a meta-analysis research paper concluded. ‘These effects were shown consistently across groups with varying baseline eGFR values.’ 13
The future of pharmacy care
As the medicines experts in the healthcare team, pharmacists are essential for ensuring safe and effective pharmacotherapy in kidney disease patients, Ms Robson says.
‘Besides the traditional roles of verifying dose accuracy and reviewing drug interactions, pharmacists can recommend treatments – such as ACE inhibitors and SGLT2 inhibitors – that have been shown to slow the progression of kidney disease,’ she says.
Pharmacists can also offer self-management counselling, review the potential symptoms of worsening kidney function, provide advice on adverse effects from medicines, and assist with strategies for medicine adherence, she adds.
‘At Kidney Health Australia, we welcome any initiative that will improve outcomes for people living with kidney disease – it is absolutely necessary that we place greater focus on the early detection, diagnosis and management of CKD, and pharmacists are well placed to do this,’ Ms Robson says.
‘Kidney Health Australia has recently partnered with the Pharmaceutical Society of
Australia to deliver educational programs to primary care providers and pharmacists in the community, stressing the need for at-risk patients to get a Kidney Health Check.’
Patient care and screening initiatives in community pharmacy, she adds, will allow pharmacists to play a key role in supporting Kidney Health Australia’s goal of ending
dialysis by 2050.
References
- Kidney Health Australia. Symptoms of kidney disease. At: https://kidney.org.au/your-kidneys/what-is-kidney-disease/symptoms-of-kidney-disease
- National Kidney Foundation. Pharmacists and chronic kidney disease. At: https://www.kidney.org/professionals/ckdintercept/pharmacists-and-chronic-kidney-disease
- Kidney Health Australia. Kidney health check. At: https://kidney.org.au/your-kidneys/know-your-kidneys/know-the-risk-factors/kidney-health-check
- Tesfaye W, Krass I, Sud K, Johnson DW, Van C, Versace VL, et al. Impact of a pharmacy-led screening and intervention in people at risk of or living with chronic kidney disease in a primary care setting: a cluster randomised trial protocol. BMJ Open. 2023;13(12):e079110. At: https://bmjopen.bmj.com/content/13/12/e079110. BMJ Open
- Ardavani A, Curtis F, Hopwood E, et al. Effect of pharmacist interventions in chronic kidney disease: a meta-analysis. Nephrol Dial Transplant. 2025;40(5):884–907. At: https://academic.oup.com/ndt/article/40/5/884/7816383
- Australian Indigenous HealthInfoNet. Latest information and statistics on kidney health. At: https://healthinfonet.ecu.edu.au/learn/health-topics/kidney/latest-information-and-statistics-on-kidney-health/
- CARI Guidelines. First Nations Australian guidelines. At: https://www.cariguidelines.org/first-nations-australian-guidelines/
- Closing the Gap. At: https://www.closingthegap.gov.au
- Oosting IJ, Colombijn JMT, Kaasenbrood L, Liabeuf S, Laville SM, Hooft L, et al. Polypharmacy in patients with CKD: a systematic review and meta-analysis. Kidney360. 2024;5(6):841–850. At: https://pubmed.ncbi.nlm.nih.gov/38661553/. ScienceDirect+1
- Wright J, Glenister KM, Thwaites R, Terry D. The importance of adequate referrals for chronic kidney disease management in a regional Australian area of nephrologist workforce shortage. Aust J Gen Pract. 2018;47(1–2):58–62. At: https://www1.racgp.org.au/ajgp/2018/january-february/the-importance-of-adequate-referrals-for-chronic-k
- Pharmaceutical Society of Australia. Australian Pharmaceutical Formulary. At: https://www.psa.org.au/media-publications/australian-pharmaceutical-formulary/
- Watters TK, Scholes-Robertson NJ, Mallett AJ, Glass BD. Exploring the pharmacist's role in regional, rural, and remote kidney transplant care: Perspectives of health professionals and transplant recipients. Explor Res Clin Soc Pharm. 2025;18:100587. doi:10.1016/j.rcsop.2025.100587. PMID: 40177655; PMCID: PMC11964747
- Mahendra AI, Samsu N, Gunawan A, Rifai A. SGLT-2 inhibitors delay kidney failure progression and reduce need of dialysis in chronic kidney disease patients: a meta-analysis. Nephrol Dial Transplant. 2023;38(Supplement_1):gfad063c_2934. At: https://academic.oup.com/ndt/article/38/Supplement_1/gfad063c_2934/7196059
[post_title] => Finding the missing millions with CKD
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
