Topical Therapies for Eczema Sandra Lawton Nurse Consultant

Topical Therapies for Eczema Sandra Lawton Nurse Consultant Dermatology sandra. lawton@nuh. nhs. uk

Treatment: stepped approach to management Use a stepped approach for managing atopic eczema: • tailor treatment step to severity • use emollients all the time • step treatment up or down as necessary Provide: • information on how to recognise flares • instructions and treatments for managing flares

Treatment: stepped approach to management Mild atopic eczema Moderate atopic eczema Severe atopic eczema Emollients Mild potency topical corticosteroids Moderate potency topical corticosteroids Potent topical corticosteroids Topical calcineurin inhibitors Bandages Phototherapy Systemic therapy

Case Study Age 5 School Statement Sleep Terrible Repeat Prescriptions+++++ Chaotic routine Admission

Emollients Which one is best? ? ? Soap Substitutes Bath Oils Shower Moisturisers Others

Effects of Emollients Soothe Anti-inflammatory Soften Anti-pruritic Hydrate Steroid-sparing effect Protect

Additives Emollients may have ingredients added : preservatives such as chlorocresol and parabens) antiseptics such as benzalkonium chloride, antipruritics such as lauromacrogols). These added ingredients can act as irritants or allergens and provoke sensitisation or an immune response.

Humectants are substances introduced into the stratum corneum to increase its water-holding capacity. The mode of action involves the active movement of water from the dermis to the epidermis. Humectants include propylene glycol, lactic acid, urea and glycerol. Some creams and lotions contain a mixture of occlusive and humectant substances – the humectant draws water into the epidermis, while the occlusive element ensures that it is trapped there.

Bathing is useful for cleansing the skin, removing scale and previous topical therapies. Bathing will also hydrate the skin and this is an ideal time to apply an emollient providing a lipid film, which prevents water evaporation from the epidermis.

Emollient bath additives Aveeno bath oil® Balneum bath oil® Cetraben bath additive® Diprobath additive® E 45 emollient bath oil® Hydromol bath additive® Oilatum emollient bath additive® Oilatum shower emollient® Emollient bath additives with added antibacterial Dermol 600 bath emollient® Dermol 200 shower emollient® Emulsiderm liquid emulsion® Oilatum Plus bath additive® Bath Oils

Bath oils should disperse if added to bath water – not be an oil slick Follow instructions re quantity added to bath water Irritant effect – did not follow instructions regarding how many capfuls of Oilatum Plus Bath Oil

Skin Moisturisers for Dry Skin

Considerations when prescribing emollients Patients Age Parent / patient choice Patients Lifestyle Appropriateness Previous Topical Therapy Cost Adequate Supplies Availability Demonstrate

Other Issues for patients Does it smell? Texture and consistency – how easy it is to apply? Does it make the skin too shiny? Does it make clothes greasy? Packaging – tubes and pumps are popular. Can it be used as a soap substitute? Is it so greasy that it spoils school work? Does it sting?

Treatment: emollients Emollients should be: • unperfumed • used every day • prescribed in large quantities (250– 500 g/week) • easily available to use at nursery, pre-school or school.

Cradle Cap

Hobbies

Head Lice

Treatment: topical corticosteroids Potency should be tailored to severity: • mild potency for face and neck, except for 3– 5 days of moderate potency for severe flares • moderate or potent preparations for short periods only for flares in vulnerable sites • do not use very potent preparations in children without specialist dermatological advice

Potency Examples Mild Hydrocortisone 1% Moderately potent Clobetasone butyrate 0. 05% (Eumovate) Potent Betamethasone 0. 1% (as valerate) (Betnovate) Hydrocortisone butyrate (Locoid) Very potent Clobetasol propionate 0. 05% (Dermovate)

Application Age Disease severity Surface area Amount : Finger tip method v tube size Frequency : Site 1 v 2 x daily. Occlusion Vehicle Other treatments Bursts Patient preference

Atopic Eczema

Atopic Eczema

Local side-effects spread and worsening of untreated infection; thinning of the skin irreversible striae and telangiectasia; contact dermatitis; perioral dermatitis acne at the site of application in some patients

Tachyphylaxis “Loss of effect” Depends upon: Usage frequency Potency Is reversible Recommend change of topical steroids

Topical Calcineurin Inhibitors Second line treatment for atopic eczema • Pimecrolimus cream (Elidel) • Tacrolimus 0. 03% or 0. 1% ointment (Protopic) Effective, and increasingly used Used to prevent flares Initiated by physician with interest in dermatology Unknown long term risk of skin cancer

Bandaging and suits To improve emollient effect • Wet/dry garments • Young infants with very dry skin To cover areas to stop scratching • Impregnated bandages eg ichthopaste/steripaste • Older children with limb or finger eczema

Education and adherence to therapy Spend time educating children and their parents or carers about atopic eczema and its treatment. Provide written and verbal information with practical demonstrations about: • • how much of the treatments to use how often to apply treatments when and how to step treatment up or down how to treat infected atopic eczema.

NICE Guideline Atopic eczema in children Management of atopic eczema in children from birth up to the age of 12 years www. nice. org. uk/CG 057

www. nottinghameczema. org. uk