The chemist and druggist, 18/25. December 2010 (issue 6778)

%JfU CLINICAL ZONE ▼19 Eczema: part 2 CLINICAL ^ 21 Pharmacokinetics BUSINESS ^ 26 Category M Eczema: part 2 The treatment options and stepped-care management of eczema Supported by GENUS PHARMACEUTICALS Chinjal Patel MRPharmS PCDip The management of eczema involves the early identification and avoidance of triggers and the implementation of a stepped-care approach to treatment, as recommended by Nice.1 This means increasing treatment when the condition is severe and reducing it when a flare is controlled. First-line treatments include emollient therapy, topical corticosteroids and anti-infective agents. Other treatments include topical tar and antimicrobial products, topical calcineurin inhibitors, phototherapy, systemic treatment, bandages and medicated dressings. Emollients are the mainstay of eczema management. They restore the epidermal barrier and prevent the skin from becoming dry. Common ingredients include liquid and white soft paraffin. Emollients are available in several forms, including creams (the most acceptable form to patients), ointments (most effective, but messy) and lotions (for mild dryness on the scalp and hairy areas). Bath emollients and emollient shower gels should be used as an adjunct to standard topical emollients. Soap substitutes such as emulsifying ointment are recommended, as soap can remove natural oils and cause the skin to become dry and shed further skin cells. Emulsifying ointment is effective in treating cradle cap in babies. Topical emollients should be smoothed onto the skin using downward strokes in the direction of hair growth, as rubbing them in can increase the risk of folliculitis. They should be used liberally all over the body as frequently as needed to prevent eczema flare-ups. There is no specific ranking order of emollients, and choice is mainly down to the site and severity of the condition and patient preference. Often several different emollient preparations are used together to achieve optimal management, which is known as complete emollient therapy. Some excipients and preservatives in emollients may be potential irritants, such as fragrances and benzyl alcohol. A list of potential sensitising excipients is found in the BNF.2 Although aqueous cream is commonly used in eczema management, it has been found to cause skin irritation (possibly due to containing the skin sensitisers sodium lauryl sulfate and chlorocresol). It should therefore not be recommended as a Table 1: Topical corticosteroid potencies MILD eg hydrocortisone 0.1-2.5 per cent (for mild eczema, especially on the face and neck) MODERATE eg betamethasone valerate 0.025 per cent, clobetasone butyrate 0.05 per cent (for moderate eczema) POTENT eg betamethasone valerate 0.1 per cent (for severe eczema) VERY POTENT eg clobetasol propionate 0.05 per cent (should only be used under specialist dermatological advice) leave-on moisturiser. All emollients should be patch-tested before use on large or sensitive areas. Emollients should be prescribed in large quantities. Typical amounts used weekly are 600g for adults and 250g for children.3 CPs may prescribe adjuvant emollients to treat secondary conditions in the skin. Emollients may also contain: antimicrobials, such as triclosan for widespread or recurrent infection - lauromacrogols, for their anaesthetic and hence anti-itching properties salicylic acid, for when an exfoliating action is needed colloidal oatmeal, for its soothing, anti-itching properties humectants, such as urea and glycerine. These provide extra hydration by drawing water from the dermis into the epidermis. It is important to review emollient therapy, as the effectiveness and acceptability of an emollient can vary with time. Topical corticosteroids Topical corticosteroids are another mainstay in the treatment of eczema. They relieve inflammation and itching by inhibiting inflammatory mediators. Topical corticosteroids are categorised in the BNF2 into four groups of potency, and the least potent preparation which effectively controls the condition should always be used. Topical corticosteroids are the first-line treatment for flares of atopic eczema. The choice is based on the potency of the product and site and severity of the eczema. See table 1, above, for details.