Download Top Tips - Dermatology Top tips in Eczema, Acne and Solar

Top Tips - Dermatology
Top tips in Eczema, Acne and Solar Keratoses
Look on British Association of Dermatologists website www.BAD.org.uk for very useful patient
leaflets.
Eczema
Prevalence 15-20% school children and 2-10% adults. 80% have mild disease, < 4% are very serious.
Itching skin (pruritus) is a major symptom of atopic eczema. A vicious circle can occur, where itching
and scratching damage the skin and increase inflammation, which in turn increases the itch. Damage
to the skin from scratching can cause bleeding, secondary infection and thickening of the skin
(lichenification).
When treating a flare of eczema you need to think about:
Use of emollients;

Reducing the damage to the skin and aim to get it back to acting as an effective barrier.

Using proper amounts of an emollient (an individual may need 500g up to twice a month).

Considering the use of anti-bacterials with the emollient if there is a significant amount of
inflammation (oilatum plus in the bath or shower, Dermol 500 on the skin).

When adding emollients to an inflamed itchy skin show the patient (or parent of) how to put
it on by stroking action in the direction of the hairs and in liberal amounts rather than rubbing
it in which just increases the itch.

Generally the greasier the emollient the better the effect although you have to be mindful of
the need to be able to function during the day.

Putting a really greasy emollient (eg emulsifying ointment)on the hands, dipping them in
water and then rubbing it in over 20 minutes once a day – at night, can be really good for very
dry hands.

Always encourage the use of emollients as soap substitutes. Carrying a small tube of greasy
hand cream (eg neutrogena) can help at work or at school- both as moisturiser and soap
substitute.
Use of steroids

Use ointments rather than creams- these have fewer preservative chemicals in which can
cause contact dermatitis.

Use a stepped approach starting high and coming down. Many referrals to dermatology
clinics result in more portent steroids being given for longer.

Guidelines from the British Association of Dermatologists suggest that the best way of using
topical corticosteroids is probably twice daily for 10–14 days when the eczema is active,
followed by a 'holiday period' of emollients only. The National Prescribing Centre
recommends that, in general practice, topical corticosteroids be used in short bursts (for 3–7
days) to treat exacerbations of disease. There are some patients who can’t be controlled in
this way and who may need longer doses.

Always try to clear facial eczema with emollients if you can, if not then use mild steroids
(hydrocortisone) for a very short period of time.
Table of Steroid Strengths
Mild potency
steroids
Hydrocortisone
Face, childhood
eczema, mild trunk
and flexural eczema
Moderate potency
steroids
Betnovate RD,
Betnovate 0.025%
Eumovate
Trunk
Potent Steroids
Betnovate
Elocon (momentasone)
Cutivate
locoid
Palms of hands and
soles of feet
Very potent
Clobetasol/dermovate
May be needed for
soles of feet
If using may need to
make sure anti
fungal creams are
used*
Eczema in axillae or
in groin may be
helped by use of a
combined steroid
antifungal (canesten
HC)
Make sure you give
enough for the
eczema to be used
at least twice a day
for 14 days- until
review
You may need to use
these to get control
of truncal/limb
eczema, if you can
review and step
down after 2 weeks
Make sure if used
you follow up and
step down
Antibiotic Use
Eczema that is inflamed from scratching is very often further inflamed by low grade bacterial
infections or by the inflammatory effect of “superantigenic toxins” associated with bacterial growth.

This is most easily controlled by fucidic acid in combination with a steroid (fucidin H and
fucibet), good practice would suggest that you step down to plain steroid use once everything
is under control.

Flare up of eczema can often be triggered or maintained by an infectious “portal”. Affecting
the regional skin environment. Always look for and treat fungal web space infections in the
feet, even if you can’t see athletes foot in a really infected leg, or look for otitis externa if you
have an an upper body flare. When recurrent infections occur, perform nasal swabs in the
family and treat with bactroban nasal ointment. Nasal carriage may not clear with oral
antibiotics. Hand eczema can be associated with a fungal infection in the feet (ID reaction).

If the infection is widespread look carefully for blisters (Eczema herpeticum), prescribe
acyclovir and an anti-staphylococcal antibiotic – not a steroid ointment and ring the
dermatology department for advice, if you think this is present. A delay in treatment whilst
waiting for an appointment can be very serious.

Infected eczema will usually need 2 weeks of oral, anti- staphylococcal antibiotics and
steroids.
Other things to remember

Remove the itch- use of antihistamines, sedating ones work best at night, and you may need
to double the dose or use a non sedating one as well in the day.

Cotton clothes are less likely to aggravate an inflamed skin.

Advise people to avoid hot baths or showers.

Advise keen swimmers not to give up swimming but to make sure they wash off all the
chlorine and use loads of emollients after a quick shower.

Topical calcineurin agents (pimecrolimus ) can be used on the face and neck to reduce sterid
use. Topical tacrolimus is licenced for moderate to severe eczema. These are often best
started after specialist assessment.
Acne
Mild to moderate Acne
Topical Treatments

If the acne has a very comedonal aspect to it then look to use topical retinoids eg tretinoin
or adapalene. These can be quite inflammatory but use them alt day and build up if necessary.

Topical antibiotics erythromycin (in Zineryt) and Clindamycin (in dalacin) are useful if there is a
popular element – these can also be useful in combination with a topical retinoid.

Benzoyl Peroxide gel works by depriving P Acnes of its favoured anaerobic conditions and will
work well with a topical (or oral ) antibiotic. It is bleach so only sleep on white pillows and
warn that it might bleach hair.
Oral treatments

Tetracyclines are a good first line of treatment BUT they work best by being taken on an
empty stomach – not always possible in adolescent males. Beware of rare Benign Intracranial
hypertension and look in fundi if headaches are reported.
Start with 500mg bd tetracycline or 100mg doxycycline. Take at least one hour before meals. You
will need 4 – 6 months before its full effect is seen.
Erythromycin 500mg a good alternative, especially in women of childbearing age.
Hormonal treatment
Women can be given a combined oral contraceptive with cyproterone or one of the newer
gestodene/ progesterones. Risk of long term use of Dianette vs using treatments such as
Roaccutane need to be taken into account.
Referral to Dermatology
Some acne is so severe, widespread or scarring that the treatments above have little or no effect.
When referring to dermatology make sure you have excluded any history of depression or mental
health problems and make sure that women, if at all possible are started on a Long Acting
Reversible Contraception(LARC) before they attend. Everyone should know about the risk of
suicide and extreme teratogenicity of roaccuatne before they go to the clinic. The B.A.D leaflets
are very useful in making this clear.
Solar Keratoses
These are premalignant conditions cause by solar damage. They present as scaley lesions on
chronically exposed adult skin. They have a low risk of progression to squamous Cell Ca (1:500 per
year) and may sometimes involute following sun protection.
The mainstay of treatment is:

Sun avoidance

Self-monitoring
Treatment

A urea containing emollient (eg Calmurid) for fine diffuse scaling. 2% salicylic acid BP can be
used to reduce scalp scaling.

3% diclofenac (solaraze) gel is good for diffuse superficial lesions. Use bd for 3 months.

Efudix bd for 21 days or alternate days (od) for 8 weeks. This will cause an inflammatory
response and will “seek” out areas around which aren’t apparent to the naked eye – warn the
patient to expect redness, soreness and crusting. Don’t use around the eyes or mouth and
limit sun exposure whilst being used, some people are helped by using Vaseline on
surrounding skin.. This is good to use if you doesn’t have a primary care cryotherapy service.

Cryotherapy (2 x 5 – 10 second freezes) good for single lesions.
Always review after 6 weeks and consider referral if as lesion proves resistant to treatment.
Bowens Disease
This is a form of in situ SCC. It typically presents as a gradually enlarging , well demarcated , red , scaly
plaque. You can get multiple lesions and often a biopsy may help to exclude a differential diagnosis of
superficial BCC.
Advice is the same as for solar keratosis.
Treatment once confident with the diagnosis;

Efudix bd for 3- 6 weeks

Cryotherapy if very early
If the lesion ceases to be flat and looks like it is forming a tumour refer to Dermatology through 2 ww.
Refer if digital or genital to dermatology.