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

CPD ZONE CLINICAL ▼ 19 Eczema: part 2 CLINICAL ▼ 21 Pharmacokinetics BUSINESS ^ 26 Category M Cream-based topical corticosteroids are more suitable for moist, weeping or infected eczema (to avoid occlusion), whereas ointment-based topical corticosteroids are recommended for dry, cracked, scaly, lichenified skin. Topical corticosteroid lotions are indicated for inflamed, hairy, widespread or exudating lesions. For those patients who have been previously diagnosed with atopic eczema, pharmacists can sell hydrocortisone (mild potency) and clobetasone butyrate 0.05 per cent (moderate potency) over the counter. Hydrocortisone is indicated for treatment of mild to moderate atopic eczema for a maximum of one week. It cannot be sold for use in children under 10 years of age, for use on the face, or for women who are pregnant.4 Clobetasone 0.05 per cent cream is indicated for the short-term treatment and control of small patches of moderate eczema and dermatitis, including atopic eczema and primary irritant and allergic dermatitis, in patients who are aged 12 or over.5 The suitability of the product and the diagnosis should be confirmed on supply. Topical corticosteroids should be rubbed into the skin sparingly up to twice daily. The fingertip unit1 can be used to quantify how much product should be used. One fingertip unit is the amount of cream or ointment squeezed out of the tube from the tip of the patient's index finger to the first crease. It is enough to treat an area of skin twice the size of the flat of an adult's hand with the fingers together. Patients should wait several minutes after applying an emollient before a topical steroid is applied to avoid diluting the steroid. Anti-infective agents Short courses of oral antibiotics - such as flucloxacillin or erythromycin - are recommended for eczema if there are signs of bacterial infection. Topical antibiotics are not generally recommended due to the risks of resistance and sensitisation. Oral aciclovir 400mg five times a day for five days is prescribed for severe eczema herpeticum. Ketoconazole shampoos are available to treat severe seborrhoeic eczema on the scalp. Tar and antimicrobial products Tar has anti-pruritic and anti-inflammatory properties and is available in several topical forms over the counter. Medicated shampoos containing antimicrobials, such as pyrithione zinc and selenium sulphide, are available for seborrhoeic eczema on the scalp. Topical immunosuppressa rits Two topical calcineurin inhibitors, tacrolimus and pimecrolimus, are available to treat atopic eczema. Treatment with either of these is normally initiated by a dermatologist when conventional therapy has been unresponsive. Tacrolimus is recommended for moderate atopic eczema on face and neck of children aged two to 16 years, while pimecrolimus is recommended for moderate to severe atopic eczema in patients older than two years. Calcineurin inhibitors do not cause skin thinning like corticosteroids. They are used if topical steroids are ineffective, or if continued use increases the risk of adverse skin effects, such as skin atrophy. Emollients should not be applied to the same area within two hours of applying tacrolimus ointment. However, emollients can be applied immediately after the application of pimecrolimus cream. Adverse effects Occasionally, sensitivity to ingredients used in topical treatments may cause a rash, and blockage of hair follicles may lead to folliculitis. Topical corticosteroids may cause localised stinging, burning, depigmentation and thinning of the skin. Prolonged excessive potent steroid use may cause irreversible striae atrophicae (permanent stretch marks due to loss of elasticity in the dermis) and telangiectasia (dilated blood capillaries). Particular care must be taken to ensure topical steroids don't get into the eye as they can cause glaucoma. Parents and carers may also be non- compliant with topical steroid treatment due to concerns about their side effects (steroid phobia). Tacrolimus and pimecrolimus may cause local burning sensation, pruritis and erythema. Other treatments Phototherapy with UVA, UVB, and psoralen plus UVA (PUVA) may be considered by specialists for refractory chronic atopic eczema. The mechanism of action is not fully understood, but has shown to have an immunosuppressant action. Patients should be advised to avoid sunburn from natural sunlight during treatment. Oral systemic treatment may be considered for severe eczema. Options include ciclosporin, azathioprine and alitretinoin (for severe hand eczema). Sedating antihistamines may be prescribed for severe itching at night. Medicated dressings (containing zinc oxide paste, coal tar or ichthammol) may be used on top of a mild topical corticosteroid to treat non- infected chronic lichenification. Wet cotton tubular bandages may also be used on top of emollients or topical steroids for short-term treatment of flares of non-infected chronic lichenified eczema. These are then over-wrapped with dry bandages. Whole-body occlusive dressings or whole-body dry bandages should not be used as first-line treatments. Compression bandaging may be used in patients with venous eczema for the treatment of any underlying varicose veins or deep vein thrombosis. Complementary therapies such as homeopathy, herbal medicine, massage and food supplements have not been adequately assessed and cannot be recommended. National Eczema Society. Tel. 0207 281 3553. Helpline: 0800 089 1122. www.eczema.org British Association of Dermatologists www.bad.org.uk Advice for patients Adequate compliance with the skin care regimen is essential to the optimal management of the condition. Pharmacists can make several interventions to improve compliance with therapy. These include: Demonstrating how to apply topical treatments, how much of each product to use, and explaining the fingertip unit. Parents and carers should be counselled to overcome any barriers to 'steroid phobia'. Encouraging adequate skin hydration and explaining how effective emollient therapy has a 'steroid-sparing' effect (a lower dose of steroid is needed to treat a flare). Advising the patient to avoid trigger factors. • Advising the patient to seek medical advice if the condition is causing psychological problems, stress, sleep disturbances or other concerns. Checking the correct use of eczema management products with an MUR and, if necessary, ensuring adequate supplies of emollients are prescribed. Attaching a dispensing label to the individual container (eg tube or bottle). Providing details of patient support groups (such as the National Eczema Society). Advising patients that wearing cotton clothing can help keep the skin cool. However, patients should be advised to avoid irritant clothing such as wool and fabric softeners. • Informing patients that the early identification and treatment of flares can help reduce their severity. Primary Care Dermatology Society www.pcds.org.uk Chinjal J Patel MRPharmS PC Dip is a community pharmacist in Oadby, Leicester. Download a CPD log sheet that helps you complete your CPD entry when you successfully complete the 5 Minute Test for this Update article online (p21). References 1. Nice. Atopic eczema in children. Management of atopic eczema in children from birth up to the age of 12 years. Nice clinical guideline 57. Dec 2007. 2. BNF60 September 2010 3. CKS. Eczema-atopic. Clinical Knowledge Summaries 2010; www.cks.nhs.uk/eczema_atopic 4. www.medicines.org.uk/EMC/medicine/ 23417/SPC/Hc45+Hydrocortisone+Cream 5. www.medicines.org.uk/EMC/medicine/16111/ SPC/Eumovate+Eczema+%26+Dermatitis+0.05% 25+Cream NEXT TIME Update will return in the New Year with a two-part look at oral health on January 15