Symptoms in the Pharmacy : skin disorders 2

Eczema and dermatitis

Treatment timescale

 
Most cases of mild to moderate atopic eczema, irritant and allergic
dermatitis should respond to skin care and treatment with OTC
products. If no improvement has been noted after 1 week, referral to
the doctor is advisable.

Management
Skin rashes tend quite understandably to cause much anxiety. There is
also a social stigma associated with skin disease. Many patients will
therefore have been seen by their doctor. Pharmacists are most likely
to be involved when the diagnosis has already been made or when the
condition first presents but is very mild.
However, with increasing recognition that patients can manage mild
to moderate eczema, and as much of the management involves advice
and the use of emollients, the pharmacist is in a good position to help,
with short-term use of OTC topical steroids where needed. Where the
pharmacist is able to identify a cause of irritant or allergic dermatitis,
topical hydrocortisone or clobetasone may be recommended.

Emollients
Emollients are the key to managing eczema and are medically inert
creams and ointments which can be used to soothe the skin, reduce
irritation, prevent the skin from drying, act as a protective layer and
be used as a soap substitute. They may be applied directly to the skin
or added to the bathwater.

There are many different types of emollient preparation that vary in
their degree of greasiness. The greasy preparations such as white soft
paraffin are often the most effective, especially with very dry skin, but
have the disadvantage of being messy and unpleasant to use. Patient
preference is very important and plays a major part in compliance
with emollient treatments. Patients will understandably not use a
preparation they find unacceptable. 

Patients may need to try several
different emollients before they find one that suits them, and they may
need to have several different products (e.g. for use as a moisturiser,
for use in the bath, for use as a soap substitute when washing or
showering). Emollient preparations should be used as often as needed
to keep the skin hydrated and moist. Several and frequent applications
each day may be required to achieve this.

Standard soaps have a drying effect on the skin and can make
eczema worse. Aqueous cream can be used as a soap substitute. It
should be applied to dry skin and rinsed off with water. Proprietary
skin washes are also available. Adding emulsifying ointment or a
proprietary bath oil to the bath is helpful. Emulsifying ointment
should first be mixed with water (1 or 2 tablespoonfuls of ointment
in a bowl of hot water) before being added to the bath to ensure
distribution in the bathwater. Some patients with eczema believe,
incorrectly, that bathing will make their eczema worse. This is not
the case providing appropriate emollient products are used and standard
soaps and perfumed bath products are avoided, and in fact,
bathing to remove skin debris and crusts is beneficial.

Advice
This could include the identification of possible aggravating or precipitating
factors. If the history is suggestive of an occupationally
associated contact dermatitis, then referral is advisable. The doctor
may feel in turn that referral to a dermatologist is appropriate. It is
sometimes necessary for a specialist to perform patch testing to identify
the cause of contact dermatitis.
Further advice could be given regarding the use of ordinary soaps
that tend to dry the skin and their alternatives (soap substitutes). If
steroid creams have been prescribed and emollients are to be used, the
pharmacist is in a good position to check that the patient understands
the way in which they should be used.

Topical corticosteroids
Hydrocortisone cream and ointment and clobetasone 0.05% can be
sold OTC for a limited range of indications. Topical hydrocortisone
OTC is licensed for the treatment of irritant and allergic dermatitis,
insect bites and mild to moderate eczema. OTC hydrocortisone is
contraindicated where the skin is infected (e.g. athlete’s foot or cold
sores), in acne, on the face and anogenital areas. Children aged over
10 and adults can be treated, and any course must not be longer than
1 week. Only proprietary OTC brands of topical hydrocortisone can
be used; dispensing packs may not be sold.
Topical clobetasone 0.05% is a P medicine for the short-term treatment
and control of patches of eczema and dermatitis in people aged
12 and over. The indications include atopic eczema and primary
irritant or allergic dermatitis and exclude seborrhoeic dermatitis

Antipruritics
Antipruritic preparations are sometimes useful although evidence of
effectiveness is lacking. The itch of eczema is not histamine-related so
the use of antihistamines other than that of sedation at night is not
indicated. Aqueous calamine cream can be used and adding 1%
menthol gives additional antipruritic and cooling actions.
Crotamiton can reduce the discomfort of itchy skin and is available
in cream and lotion forms. A combination product containing
crotamiton with hydrocortisone is available. Indications for use
are the same as for topical hydrocortisone for contact dermatitis
(irritant or allergic), insect bites or stings, and mild to moderate
eczema. The same restrictions on use apply (see ‘Topical corticosteroids’
above).

Support for patients
The National Eczema Society provides information and support
through its website www.eczema.org, a telephone helpline and written
information.