Download Bathing - NHS Choices

BATHING
Should be daily to keep the skin as clean as possible, for no longer than 10 mins.
An emollient can be applied before or during bathing as a soap substitute.
PAT SKIN DRY after bathing-Do not rub hard with a towel, as this takes out
the bath oils that have just been applied and will irritate the skin.
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EMOLLIENTS AND MOISTURISERS
Contain varying amounts of water and oil. The greasier ones are best for dry skin
or night time use.
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BATH ADDITIVES
Balneum
Balneum Plus – contains an anti-pruritic agent (anti itch) ,may make
bath brown
Oilatum – or Oilatum Fragrance Free
Oilatum Plus – has antiseptic qualities, can sting-not recommended.
Dermol 600 – very good for children who get infected skin,
antimicrobial
Aveeno’s bath sachets – can be used to soften bath water if child gets
red
in the bath.
Plain Water – this is alright if plenty of emollient is used after bathing.
Can be
acceptable to prevent bath being slippery and damage to toys.
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SHOWERS
Can be an alternative – use bath oil or emollients applied directly to wet
skin and then rinse off.
Dermol 200 – used as a shower gel substitute, has antimicrobial
properties
Dermol 500 - a soap substitute, again when skin infections frequent,
used for bath or shower.
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WATER SOFTENERS
May be helpful, although are costly
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Aqueous – cheap, high water content, good as a bath soap substitute,
BUT can sting and irritate the skin- not recommended as an emollient.
Diprobase Cream – less contamination in a 500g pump, good for use
with other carers and at school, good moisturising effect – despite being
a cream very acceptable to child and family, good as a daytime
moisturiser.
Diprobase Ointment – greasier than Diprobase cream, sometimes more
acceptable than the more greasier emollients.
Epaderm – very greasy, although does not leave a residue on carers
hands. Excellent as the sole emollient for a child. Good for nighttime use only, if not acceptable by carers for day time use. Does
not appear to cause irritation of the hair follicles as other greasy
moisturisers do. A FAVOURITE WHEN USED ALONE and/or
UNDER WET/DRY WRAPS. Can be decanted into another
container and water added for use during the day.
50-50 White soft paraffin - cheap, very greasy and messy, can cause
folliculitis when used under wraps.
Doublebase – greasy, useful for wraps and dry skin.
Aveeno Oatmeal a light emollient, useful for facial eczema. Can be very
soothing
Cetraben – cream, which can be very effective. Very cooling and comes
in a pump dispenser.
Dermol 500 Lotion – very light creamy lotion, less contamination as a in
pump.
Dermol Cream – a thicker cream more useful than Dermol 500 as an
emollient.
All Dermol products useful to help reduce skin infections.
All emollients should be applied even when the skin looks good and applied in
the direction of the hair growth. The most effective emollient is the one the
child and family will use.
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STEROIDS
Medical opinion favours adequate use of steroids to get condition under control.
Once under control if possible step down the steroid ladder. Ointment or cream
preparations are available, but ointments are the first choice as they work more
effectively on dry skin and soak into creases more effectively. Also be aware that
steroids under occlusion increase the potency
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Step 1: Hydrocortisone – 0.5%, 1% and 2.5% strengths for BD use,
very mild and very safe. Can be used on faces.
Step 1-2: 10% Propaderm in white soft paraffin – BD use. Potent in
its neat strength, but weak when in this 1 in 10 dilution. Side effects of
hydrocortisone, excellent for widespread eczema and use under wet
wraps. Caution as confusion possible with Epaderm; both come in 500g
pots. Liberal amounts can be used for moderately severe eczema i.e.
5year old 500g in 1st week, 250g in 2nd week, 125 in 3rd week and then
stop. However expensive to produce (about £100 per pot).
Step 2: Eumovate – moderately potent Good for Children over 2 years
old, if Hydrocortisone is not controlling eczema.
Betnovate RD 1:4 – moderately potent. Can be used for short periods.
If needing a moderately potent steroid may be better to us Elocon, as
there are less side effects.
Step 3: Elocon – Once daily only. Potent in strength, but better
metabolised in the liver than other potent steroids. Excellent for
eczema flare ups – can be used for 2-3 days in a row to get control then
1-2 times a week. Caution and monitoring when used under 3years.
Known to sting.
Step 4: Dermovate – Very potent, not usually used on children and only
under the guidance of a dermatologist.
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TUBIFAST GARMENTS AND TUBIFAST LENGTHS
Dry or wet wrapping helps seal in the moisturisers, aids healing and can prevent
the child scratching the skin.
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Use appropriate sized Tubifast garments or lengths ordered on
prescription.
Can be used either dry or wet over copious amounts of emollients.
Wet wrap after bathing where emollients and steroids have been applied.
One layer of the tubifast garment is dampened in water prior to
application then a dry garment on top.
There are leaflets, videos and other teaching aids available from Seton
Healthcare (0161 621 2100).
Wrapping should not be carried out when the skin is infected.
Not recommended over potent steroids as this increases potency.
Takes commitment from the family so it is worth asking them to comply
for at least a week to see some benefit.
ZIPZOC
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Zipzoc is a zinc paste stocking available on prescription, but only comes
in one width and length.
Evidence has shown that Zipzoc applied to excoriated areas, particularly
around ankles and wrists aids healing and is soothing under tubifast
garments or the appropriate sized tubifast length.
It can be worn for up to 48 hours. It is applied over copious amounts of
emollients and should be temporarily rolled back during the day to reapply more emollient.
Not to be used on infected skin.
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INFECTIONS
ALLERGY TESTING
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Often parents wish to find a cure for their child’s eczema. They
experiment with their child’s diet and often request allergy testing.
Unfortunately, allergy testing such as skin prick testing and the RAST
blood test can not diagnose the causes of eczema as the child will not
produce antibodies. The private tests in the community looking at a wide
range of things often give insignificant and confusing results.
The general advice is if the eczema is manageable with standard
treatment, then diet should not be tampered with. If the eczema is poorly
controlled and causing considerable problems, then diet can be looked at
as a possible trigger. Foods such as cow’s milk should only be omitted
with advice from a dietician.
Allergy testing is appropriate for children who have Type I
hypersensitivity food reactions such as immediate hives, lips or facial
swelling (angio-oedema), vomiting or the more severe reactions such as
breathing difficulties or hypotension leading to collapse. These children
should be given advice on how to manage these reactions and referred to
the allergy clinic.
Both topical and oral antibiotics to be used with caution due to increased
incidence of resistance to antibiotic therapy.
 Fucidin H used on most cases of infected eczema. If the child has been
using moderate/potent steroids then for infection add Fucidin without the
Hydrocortisone. To use 2-3 x 30g tubes of Fucidin H/ Fucidin twice
daily, over a week. If this is ineffective consider for referral for
antibiotics.
 Flucloxacillin is the appropriate oral antibiotic but is often unacceptable
to children, due to the taste. Only use if eczema is widespread.
 Also consider whether it is fungal- infections in sweaty or wet areas such
as under arms or nappy areas are often fungal and require anti-fungal
topical treatment.
 If unclear consult a dermatologist or swab the area and speak to a
microbiologist. Added to this consider swabbing the nostrils of all the
family if infection not clearing as they may need treating with Naseptin
or what is currently recommended by the microbiologist.
 Introduce Dermol products to reduce risk of infection.
 If the eczema is very inflamed, not obviously infected, but is not
responding to topical steroid, it is generally infected and requires topical
antibiotics.
 Once infection has gone wetwrapping can be commenced with the
appropriate steroid or Zipzoc.
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Also consider if the eczema is infected by the herpes virus, known as
herpeticum. Some children can become unwell very quickly with this
and need immediate dermatology treatment.
Tacrolimus 0.03% (patients aged 2-16yrs) and Tacrolimus 0.1 % (patients aged
16 and over). For severe eczema and only under dermatology supervision.
Pimecrolimus 1% (patients over 2yrs). For mild to moderate eczema. G.P.can
prescribe. To use twice daily until clearance occurs. Then discontinued and
restarted at first signs of symptoms.
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Both drugs are immunosuppressants and useful when steroids have failed or when
there has been long term use for steroids. Often most useful on face and neck
areas. Some cautions (in addition see data sheets)
 Neither drug should be used as first line management.
 Not used when infection present or with live attenuated vaccines.
 Skin irritation can occur which usually resolves as treatment continues.
 Sun protection needed due to immunosuppressant properties.
 Not to use topical steroids on same site.
 Not to use under occlusion.
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TOPICAL IMMUNOSUPPRESSANTS
Commnuity Children’s Nurses
Cornwallis House
Cornwallis Road
Cowley
Oxford
Oxfordshire
OX4 3NH
Tel. no. 01865 747962
Fax no. 01865 401185
ECZEMA GUIDELINES
FOR TREATMENT
IN CHILDREN
Clinics held in Oxford, Abingdon,
Bicester, Banbury, Chipping Norton.
Community Children’s Nurses
Revised by Elaine Cleaver/Judith Ward - July 2005.
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