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Improve your MURs on emollients and topical corticosteroids

Improve your knowledge of these treatments for atopic eczema ahead of your next consultation

What is atopic eczema?

There are many different types of eczema with different severities; the most common type is atopic eczema. This dry skin condition causes the skin to become red, itchy and sometimes cracked. It is common in children and will usually clear up by adulthood, but if it does not it can turn into a long-term condition. Most commonly affected areas are elbows, knees, neck, hands, cheeks and scalp. The skin will usually go through periods of flare-ups when the condition becomes worse and other times when symptoms are less noticeable.

 

The cause of atopic eczema is unknown, although it is thought to be a type of allergy. It is more likely to occur when atopic diseases – eczema, asthma and hayfever – run in the family. Certain triggers, such as soap, stress, the weather (hot or cold) or certain foods, can cause flare-ups of the symptoms.

 

The most common complication that can occur with eczema is a bacterial infection, especially if the skin is broken, which usually happens as a result of scratching. The signs to look out for are weepy skin, yellow crusts, swollen or sore skin. In some more severe cases, patients report fever and feeling unwell. Treatment is with a topical or oral antibiotic.

 

Managing atopic eczema

Eczema can be managed, and regular treatment can improve the long-term symptoms and reduce flare-ups or complications. Eczema is most commonly managed with emollients (moisturisers) and topical corticosteroids.

 

Emollients are available in a variety of types and selection is based on the particular circumstances. The key to using emollients is to apply them liberally, regularly and frequently – up to three or four times a day, even when there are no symptoms ­– to prevent flare-ups. Patients should be prescribed around 10 times more emollient than corticosteroids.

 

There is no evidence to suggest which emollient is best but patient acceptability is essential to ensure that they will use the product. This can mean trial and error to find the most suitable emollient(s) for a particular patient. Ointments are greasy and sticky but more effective for very dry skin and their effects last longer than creams. Because they generally do not need preservatives there is less risk of sensitisation and they are more soothing on the skin. They can be useful to use at night but should not be used on weepy skin. Creams are more cosmetically acceptable but they do not last as long on the skin as ointments and often contain preservatives that can irritate.

 

Other products include gels, lotions, washes, and bath and shower additives. Some excipients can offer further advantages. For example, urea can soften keratin and hydrate the skin, antiseptics are useful to prevent infection when the skin is broken and lauromacrogols can help with itchy skin. Aqueous cream is no longer recommended because of associated skin reactions, as highlighted by the MHRA, which is thought to be due to sodium lauryl sulfate.

 

Topical corticosteroids are used during flare-ups to resolve symptoms but they should not be used continuously or for long periods. They are generally used once or twice daily for seven to 14 days. After 14 days, if symptoms have not improved, patients should go back to their prescriber.

 

The choice of potency will depend on the severity and location of the eczema. Milder products are recommended for milder symptoms, infants, and children and for use on the face and genitalia. The lowest effective potency and duration should be used to prevent side effects. Side effects resulting in changes to skin structure and colour can occur with prolonged use.

 

Fingertip units can be used to prevent over- or under-use of the drug. One fingertip unit will be sufficient for an area of skin that can be covered by two flat hands. Patients should be encouraged to measure the affected areas with their hands and use the equivalent number of fingertip units.

 

Lifestyle and self-care advice
  • Keep skin moisturised, even if there are no symptoms, to reduce flare-ups
  • Different emollients suit different people, try different products until you find the ones that work for you
  • Continue to use emollients when using corticosteroids but leave 15 to 30 minutes between applications of corticosteroids and emollients if applying at the same time
  • Measure the affected area with your hands and use one fingertip unit of corticosteroid for an area covered by two flat hands of skin affected
  • Continue to use corticosteroids for 48 hours after symptoms have resolved to prevent relapse
  • Do not use corticosteroids for longer than two weeks; if symptoms have not improved go back to see your prescriber
  • Avoiding triggers can help to prevent flare-ups. It can be useful to keep a diary of symptoms and potential triggers to establish links so the triggers can be avoided
  • Use soap substitutes – either specifically formulated washes/bath additives or some creams and ointments can be used as soap substitutes as well
  • Avoid over-washing and very hot water when washing as this can dry the skin further
  • Avoid scratching, especially at night – this can mean using cotton gloves or mittens for infants and children
  • Pump dispensers can be more convenient and reduce the risk of product contamination

 

Getting eczema under control

Emollients These are often underprescribed and underused, which can result in poor control of symptoms leading to overreliance on corticosteroids. Check how often a patient uses their emollients, investigate reasons for underuse and suggest solutions to barriers patients are encountering. For example, if a patient’s job requires frequent hand washing, suggest they take their own emollient wash to work. If a patient prefers showers but has been prescribed bath additives, recommend a shower gel. More often than not, a lack of knowledge of the importance of emollients is the main reason for inappropriate use; the key can simply be educating patients.

 

Corticosteroids Look for clues indicating overuse. For example, quantities prescribed for the affected area, frequency of prescribing and, perhaps most obviously, ask the patient how often they use them. Again, education is essential to reduce overreliance and the risk of long-term side effects. Sometimes patients can be wary of using corticosteroids and underuse them to the point that they become ineffective. Investigate patient reasons for not using corticosteroids and allay any fears or concerns they may have; using corticosteroids correctly should limit the risk of side effects.

 

Additional treatments

Antihistamines can help with itching associated with atopic eczema. Sedating or non-sedating antihistamines can be used. More often than not, sedating antihistamines are used at night to help patients sleep as well as to reduce itching. Remember to consider the patient’s age, pregnancy or breastfeeding and preference for a sedating or non-sedating drug.

 

Antibiotics Topical antibiotics are usually prescribed and can be single or combined products with antimicrobials and/or corticosteroids. Combination products are more likely to cause sensitisation of the skin due to the additional excipients. Also, prolonged use of topical antibiotics can result in bacterial resistance. To limit these problems, these products should not be used for longer than two weeks.

 

Mary Rhodes is a lecturer at Manchester Pharmacy School, The University of Manchester

 

References
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