1. Topical Therapies for Eczema
Sandra Lawton
Nurse Consultant Dermatology

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
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. [ ]
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. [ ]

3. 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. [ ]
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. [ ]

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

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

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

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 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.

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. 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®

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

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.
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. [ ]

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
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.
[ ]

25. 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)

26. 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

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. Recommend change of topical steroids
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.
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. [ ]

36. 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