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 NOTES FOR PRESENTERS: Healthcare professionals should use a stepped approach for managing atopic eczema in children (see pages 10 and 11 of the quick reference guide). This means tailoring the treatment step to the severity of the atopic eczema. Emollients should form the basis of atopic eczema management and should always be used, even when the atopic eczema is clear. Management can then be stepped up or down, according to the severity of symptoms, with the addition of the other treatments listed in the table. [1.5.1.1] Healthcare professionals should offer children with atopic eczema and their parents or carers information on how to recognise flares of atopic eczema (increased dryness, itching, redness, swelling and general irritability). They should give clear instructions on how to manage flares according to the stepped-care plan, and prescribe treatments that allow children and their parents or carers to follow this plan. [1.5.1.2]

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 NOTES FOR PRESENTERS: Healthcare professionals should use a stepped approach for managing atopic eczema in children (see pages 10 and 11 of the quick reference guide). This means tailoring the treatment step to the severity of the atopic eczema. Emollients should form the basis of atopic eczema management and should always be used, even when the atopic eczema is clear. Management can then be stepped up or down, according to the severity of symptoms, with the addition of the other treatments listed in the table. [1.5.1.1] Healthcare professionals should offer children with atopic eczema and their parents or carers information on how to recognise flares of atopic eczema (increased dryness, itching, redness, swelling and general irritability). They should give clear instructions on how to manage flares according to the stepped-care plan, and prescribe treatments that allow children and their parents or carers to follow this plan. [1.5.1.2]

Repeat Prescriptions+++++ 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 Soften Hydrate Protect Anti-inflammatory Anti-pruritic Steroid-sparing effect

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 include propylene glycol, lactic acid, urea and glycerol. 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 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 Bath Oils Emollient bath additives Aveeno bath oil® Balneum bath oil® Cetraben bath additive® Diprobath bath additive® E45 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 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 Patients Lifestyle Previous Topical Therapy Availability Demonstrate Parent / patient choice Appropriateness Cost Adequate Supplies

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. NOTES FOR PRESENTERS: Healthcare professionals should offer children with atopic eczema a choice of unperfumed emollients to use every day for moisturising, washing and bathing. This should be suited to the child’s needs and preferences, and may include a combination of products or one product for all purposes. Leave-on emollients should be prescribed in large quantities (250–500 g weekly) and easily available to use at nursery, pre-school or school. [1.5.2.1]

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 NOTES FOR PRESENTERS: The potency of topical corticosteroids should be tailored to the severity of the child’s atopic eczema, which may vary according to body site. They should be used as follows: use mild potency for mild atopic eczema use moderate potency for moderate atopic eczema use potent for severe atopic eczema use mild potency for the face and neck, except for short-term (3–5 days) use of moderate potency for severe flares use moderate or potent preparations for short periods only (7–14 days) for flares in vulnerable sites such as axillae and groin do not use very potent preparations in children without specialist dermatological advice. [1.5.3.2]

Potency Mild Hydrocortisone 1% Moderately potent 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)

Finger tip method v tube size Application 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

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

Recommend change of topical steroids 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. NOTES FOR PRESENTERS: Healthcare professionals should spend time educating children with atopic eczema and their parents or carers about atopic eczema and its treatment. They should provide information in verbal and written forms, with practical demonstrations, and should cover: 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. This should be reinforced at every consultation, addressing factors that affect adherence. [1.6.1.1]

Atopic eczema in children 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

www.nottinghameczema.org.uk