1. Top Tips in Treating Eczema Dr James Halpern Consultant Dermatologist Walsall Healthcare NHS Trust

2. Introduction The aim of this talk: To give you practical guidance and tips in managing eczema Aimed at patients presenting to primary care Common pitfalls and mistakes Prescribing in a cost effective manner What we will not cover: Pathology Epidemiology Genetics This talk is about management!

3. TIP 1: EMOLLIENTS

4. Emollients Not all emollients are the same In general the more greasy an emollient the more effective it is, but also the more cosmetically unacceptable it is 50/50 WSP/LP is the ‘greasiest’ preparation available and if very good for dry eczema but also hardly ever used as it is poorly tolerated

5. Emollients Gels and Lotions have a high water content Are easy to rub in, leaving little shine on the skin Are poor moisturisers Useful as soap substitutes and for patients with poor compliance (eg. Teenagers)

6. Emollients Ointments are very greasy They are the best moisturisers and great for very dry skin They are poorly tolerated and hard to rub in The skin looks shiny Risk of folliculitis, heat trapping and are flammable

7. Emollients Creams are an emulsion of water and oil They are a good compromise between effectiveness and tolerability Generally the most prescribed

8. Emollients For very dry and severe eczema Always prescribe ointments For ‘standard’ eczema Use creams For mild eczema and those with poor compliance Use gels and lotions Try combining creams Use a cream during the day whilst a work/school Use a thick layer of ointment at night before bed

9. Emollients Quantities: For extensive eczema – 500g/week For moderate eczema – 500g/fortnight For mild eczema – 500g/month Always prescribe 500g large tubs £6.30£12.80

10. TIP 2: COMPLETE EMOLLIENT THERAPY

11. Complete emollient therapy Complete emollient therapy: A regular emollient A soap substitute A bath oil In most cases emollients can also be used as soap substitutes Emollient Soap Substitute Bath Oil

12. TIP 3: EMOLLIENTS WITH ANTIMICROBIALS

13. Emollients with antimicrobials For patients with recurrent infected eczema or discoid eczema Available as emollients, soap substitutes and bath oils

14. TIP 4: STEROIDS

15. Strength of steroids 1% Hydrocortisone can be prescribed for children of any age and used in any site (except the eyelids)

16. Strength of steroids Toddlers and children can use a mild steroid on the face and a Moderate steroid on the body

17. Strength of steroids Adults can use a moderate strength steroid on the face and a potent steroid on the body

18. Steroid Ointments not Creams Eczema is a dry skin condition In 99% of eczema steroid ointments should be prescribed Ointments moisturise the skin They are stronger than equivalent creams They cause less skin thinning than equivalent creams They contain less preservatives and other potential allergens Steroid creams should only be prescribed for wet, weepy eczema eg. Pompholyx

19. Frequency and amounts of Steroid Eczema is a Chronic condition Intermittent use of steroids in 7 or 10 day courses is not helpful Steroids should be prescribed for continuous, long term usage Better to prescribe a moderate steroid for continuous usage than multiple short courses of a potent steroid Sufficient quantities of steroid need to be prescribed For the body always prescribe 100g tubes In severe eczema patients can use 100g/fortnight Never prescribe oral steroids in eczema Patients always flare when steroids are stopped

20. TIP 5: AVOIDING SOAPS

21. Avoiding Soaps All soaps, body washes and shower gels need to be avoided Soaps which claim to be ‘simple, ‘gentle’ and ‘hypoallergenic’ still need to be avoided

22. TIP 6: TREATING INFECTIONS

23. Treating Infections Infected eczema needs to be treated with oral antibiotics Topical antibiotics are ineffective Fusidic acid in particular should be avoided Steroids need to be stopped for 48 hours Antiseptic emollients / bath oils can be used in addition

24. TIP 7: TREATING ITCH

25. Treating Itch Itchy eczema = Undertreated eczema Undertreated eczema needs more/stronger steroids Antihistamines are unhelpful Histamine is not involved in the ‘itch’ pathway in eczema Antihistamines cause drowsiness Tolerance to antihistamines develops quickly I only use for short periods to cover severe flares interfering with sleep – used to help sleep, not reduce itch

26. SUMMARY

27. Summary If you have a patient with eczema not responding to treatment: Are they using a greasy enough emollient? Do they have enough emollient? Are they using complete emollient therapy? Is the steroid strong enough? Are they using enough steroid? Are they still using soaps or shower-gels? Is there secondary infection?