Topical Therapies for Eczema

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

2. 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

3. Treatment: stepped approach to management

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

7. EmollientsWhich one is best??? • Soap Substitutes • Bath Oils • Shower • Moisturisers • Others

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

9. 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.

10. Humectants • 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.

11. Bathing • 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.

12. Bath Oils

13. 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

15. Skin Moisturisers for Dry Skin

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

18. 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?

19. 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.

20. Cradle Cap

22. Hobbies

23. Head Lice

24. 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

25. Potency

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

27. Atopic Eczema

28. Atopic Eczema

30. 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

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

32. 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

33. 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

35. 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.

36. 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/CG057

37. www.nottinghameczema.org.uk