Treatment of eczema

Definitions of vehicles
Additives
The bath
Corticosteroids
Antibacterials
Other treatments
NICE referral guidelines for eczema in children

Definitions of vehicles

Ointments - Oil alone, usually predominantly WSP
Creams - Water with added oil and emulsifier
Lotions - Watery cream
Oily cream - Ointment with added water
Gel - Water and other substance (protein)
Dispersing bath oils - Oil and emulsifier

Additives

Preservatives	Creams, gels and lotions require preservative to prevent bacterial growth. May cause aggravation of eczema by allergic reaction direct irritant effect eg: - parabens - chlorcresol - sorbic acid - phenoxyethanol
Antioxidants	Added to oil to prevent oxidation eg: - Vitamin E
Emulsifiers	Stabilise oil and water mixtures
Lanolin	Acts as emulsifier and gives "pleasant feel". May cause allergy
Fragrances

The bath

Functions

Clean skin and prevent infection
Moisurise the skin
Prepares skin for other treatments
Enjoyable event

Additives

Emulsifying ointment (whisk with boiling water) - effective, cheap but messy
Alpha keri - liquid paraffin + lanolin
Balneum - soya
Bath E45 - liquid paraffin
Oilatum Emollient - liquid paraffin and lanolin

AVOID SOAP!

Instead use

Diprobase cream (pump dispenser)
Unguentum Merck (pump dispenser)
Wash E45
Aqueous cream
Emulsifying ointment

Followed by

a moisturiser (emollient)

This provides a surface film of oil which slows down the escape of water. Note: Less oily preparations contain more water, additives and preservatives, therefore use as OILY a preparation as possible. Avoid preparations with urea added - irritation (eg Aquadrate cream).

Least oily
- Keri lotion
A little oilier
- Aqueous cream
- E45 cream
- Oilatum cream
- Diprobase cream
More oily
- Unguentum Merck
- Oily cream BP
- Epaderm
Most oily
- Coconut oil BP
- WSP + liquid paraffin 50/50
- Diprobase ointment
- Neutrogena dermatological cream
- WSP BP
All best applied immediately after bathing and also throughout the day THINLY

Corticosteroids

Topical!! Potency depends on

particular hormone
concentration
properties of base

Potency

Low
- Hydrocortisone 0.5%, 1%, 2.5%
Low Medium
- Eumovate (Clobetasone)
Medium
- Synalar 1:4 (Flucinolone)
- Betnovate RD (1:4) (Metamethasone)
High
- Betnovate (Metamethasone)
- Propaderm (Beclomethasone) Synalar (Flucinolone)
- Metosyn (Fluocinonide)
- Nerisone (Diflucortolone)
- Elocon (Mometasone)
Very High
- Clobetesol (Dermovate)
- Synalar Forte
- Nerisone Forte

Systemic effects

Low - Virtually never
Low medium - Unlikely except in babies
Medium - If used on extensive areas in large quantities over a long period especially under 5 years
DO NOT USE HIGH OR VERY HIGH PREPARATIONS IN CHILDREN

Local effects

Thinning
Striae
Telangiectasia

Avoid all except low and occasionally low medium to face.
Use high and very high only for one week at a time.
TACHYPHYLAXIS:
change brands within same potency group every few weeks.
POLYTHENE OCCLUSION:
Helpful in adults but rarely used in children.

Antibacterials

Suspect infection whenever there is

rapid worsening
weeping
pustules
crusting

Best treatment is baths/showers/oils/creams and moisturisers. Majority caused by staph. aureus - Flucloxacillin, Erythromycin. May get Group A strep - Penivillin V alone or added to above. If infection is recurrent: mupirocin or fusidic acid to nose, prophylactic antibiotics.

Other treatments

Potassium permanganate soaks
Antihistamines
Mild and egg free diets
Soya milk
Goats milk
Wheat avoidance
Artificial additive avoidance (colouring agents, 7- up, sprite, boiled sweets)
Evening primrose
House dust mite
Pollens
Pets
Chinese herbal medicine
PUVA
Cyclospin

AVOID

Soaps and detergents
Water
Cosmetics
Handling foods, e.g. citrus fruits, raw vegetables, onions, tomatoes/sauce
Wool and nylon
Overheating
Trainer shoes
Long fingernails
Sunlight
Low humidity
Parents with asthma, eczema or hayfever!

NICE referral guidelines for eczema in children

NICE referral guidelines 2001

Atopic eczema guidelines