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Managing dry skin conditions in the pharmacy (with a spotlight on atopic eczema)

Download the Managing dry skin conditions in the pharmacy poster here.

 

What is atopic eczema? 

Atopic eczema (AE) is a common skin condition that can cause dry, itchy and cracked skin. Although commonly a childhood condition, eczema can start at any age.(1)

AE is usually a long-term chronic condition, with intermittent flares in symptoms that persist into adulthood. However, symptoms can improve or even resolve completely during childhood.(2,3) It is estimated that 10-30% of children and 2-10% of adults are affected by atopic eczema.(4)

 

What are the causes of atopic eczema? 

The exact cause of AE is unknown. Multiple factors have been suggested as the cause of dysfunction of the skin barrier. AE is a hereditary condition and children are more likely to develop AE if one or both of their parents have it.(4)

The dry skin caused by AE is more likely to react to certain triggers – resulting in the skin becoming more itchy and painful.

Common triggers can include irritants such as soaps and detergents and environmental factors or allergens such as animal dander and pollen. Food allergens, skin infections, hormonal changes, seasonal changes and stress can all also trigger AE.(1,2)

Repeated hand-washing as per government guidelines for preventing the spread of COVID-19 can worsen dry skin and eczema on the hands.(5)

 

Differential diagnosis

Some skin conditions present with dry skin and may be misdiagnosed as atopic eczema. These conditions include:

  • Psoriasis: itchy red and flaky skin with flat-topped plaques with silvery scales.(6)
  • Allergic contact dermatitis: rash triggered by a topical allergen.(7)
  • Irritant contact dermatitis: rash triggered by frequent contact with an irritant eg soap or detergent.(7)
  • Seborrhoeic dermatitis: chronic, relapsing form of eczema with red, sharply marginated lesions with greasy scales; usually seen on ears, beard area, eyebrows, scalp, and nasolabial folds.(4,8)
  • Fungal infection: patch with slightly raised, sometimes scaly, border, and central clearing.(4)
  • Scabies or other infestations: itchy rash often seen in multiple family members.(4)
 

What is the role of the pharmacy team?

Intervention by a healthcare professional can reduce symptom severity of atopic eczema by up to 89%.*(9) Emollients, bath and/or shower preparations for dry and pruritic skin conditions should not be routinely prescribed in primary care and this means that patients are more likely to present in the pharmacy with symptoms of dry and itchy skin. The pharmacy team is therefore ideally placed to help patients manage their condition.(10)

When assessing patients, it is important that the pharmacy team:

  • uses a patient-centred approach during consultation.
  • identifies any potential trigger factors.
  • asks the patient about other symptoms. For example, dry and itchy skin may cause sleep to be disturbed, which would impact on everyday activities and affect mental wellbeing.(3)
 

Red flag symptoms

Patients with atopic eczema may be at risk of infection due to cracked or broken skin. Patients should be referred to their GP if they have symptoms of infection such as:(2)

  • skin feeling hot and sore
  • oozing and yellow crust forming
  • fluid-filled blisters
  • feverish and feeling generally unwell

Patients who are having trouble sleeping or having psychological effects as a result of atopic eczema should also be referred to their GP.(2)

 

Treatment options

The National Institute for health and Care Excellence advises emollients as first-line treatment for atopic eczema.(3)

Emollients are available in various forms, including creams, ointments, gels, lotions, sprays, washes, and bath and shower additives. They are available over the counter. Most emollients are plain, however some contain active ingredients (eg urea and lauromacrogols).(11)

It is important to take into account patient preference and dryness of the patient’s skin when recommending an emollient. Patients may need to try several before finding the most suitable – they may also need to use more than one emollient.(11)

Creams and lotions are generally better for red, inflamed areas of skin. Ointments are preferable for dry skin (that is not inflamed), but they may be poorly tolerated because they can be greasy on application and it may be better to apply them at night. Soap substitutes and bath and shower additives are an option for patients with large areas of dry skin.(11)

*Based on a nurse intervention study on 51 children with atopic eczema for one year, 2003.

 

Advise patients on emollient use

 

Straightforward skincare for your patients’ dry skin conditions and symptoms 

Add E45 Cream alongside the specialist treatment range to help your patient effectively manage their dry skin symptoms

 

*High level of humectants to draw water in. Occlusive agents to help reduce water loss. Omega fatty acids which may help support the integrity of the skin.

E45 Itch Relief Cream. Active Ingredient: Lauromacrogols 3.0% w/w, Urea 5.0% w/w Indications: Treatment of pruritus, eczema, dermatitis, and scaling skin conditions where an antipruritic and/or hydrating effect is required. Legal Category: GSL. MA holder: Crookes Healthcare Ltd, NG2 3AA. Information about this product, including adverse reactions, precautions, contra-indications, and method of use can be found here.

Hc45 Hydrocortisone Cream. Active Ingredient: Hydrocortisone Acetate BP 1.0% w/w Indications: Irritant contact dermatitis, allergic contact dermatitis, insect bite reactions, mild to moderate eczema. MA Holder: Reckitt Benckiser Healthcare (UK) Ltd, SL1 4AQ. Legal category: P. Information about this product, including adverse reactions, precautions, contraindications, and method of use can be found here.

E45 Cream. Active Ingredients: White Soft Paraffin 14.5% w/w, Light Liquid Paraffin 12.6% w/w and Anhydrous Lanolin 1.0% w/w. Indications: For the symptomatic relief of dry skin conditions, where the use of an emollient is indicated, such as flaking, chapped skin, ichthyosis, traumatic dermatitis, sunburn, the dry stage of eczema and certain dry cases of psoriasis. MA Holder: Reckitt Benckiser Healthcare (UK) Ltd, Slough, SL1 4AQ, UK. Legal category: GSL. Information about this product, including adverse reactions, precautions, contra-indications, and method of use can be found in the SPC here.

 

References

  1. British Association of Dermatologists (2020) Atopic eczema
  2. NHS (2019) Atopic eczema
  3. National Institute of Health and Care Excellence (2007) Atopic eczema in under 12s: diagnosis and management
  4. National Institute of Health and Care Excellence (2018) Clinical Knowledge Summaries: Atopic Eczema
  5. National Eczema Society (2020) Advice on coronavirus (COVID-19) for people with eczema
  6. NHS (2018) Psoriasis
  7. NHS (2019) Contact dermatitis
  8. DermNet NZ (2017) Seborrhoeic dermatitis
  9. Cork MJ, Britton J, Butler L, Young S, Murphy R, Keohane SG. Comparison of parent knowledge, therapy utilization and severity of atopic eczema before and after explanation and demonstration of topical therapies by a specialist dermatology nurse. Br J Dermatol. 2003 Sep;149(3):582-9. doi: 10.1046/j.1365-2133.2003.05595.
  10. NHS Clinical Commissioners (2019) Items which should not routinely be prescribed in primary care: Guidance for CCGs
  11. National Institute of health and Care Excellence (2018) Emollients
  12. Gov.uk (2018) Emollients: new information about risk of severe and fatal burns with paraffin-containing and paraffin-free emollients.

Job code: RB-M-22245 | Date of prep: Feb 2021

 

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Superintendent Pharmacist
Ayrshire
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