For the purpose of this article, I will concentrate on the most common type of eczema, atopic eczema. However, the treatment of atopic and non-atopic eczema is similar.
Atopic dermatitis is a chronic inflammatory skin condition that involves a complex interaction between environmental and genetic factors. The Greek word atopy means “out of place” and describes the group of disorders including eczema, asthma and allergic rhinitis and which are genetically linked. The terms “dermatitis” and "eczema" are often used interchangeably. When the term eczema is used alone, it usually refers to atopic dermatitis (atopic eczema).
Atopic eczema affects over 30 per cent of children before they reach school age and 1-3 per cent of adults in the UK. It is likely that its prevalence in Ireland is similar to the UK. It is often inherited. There is very often a link with asthma and hay fever. Atopic eczema has become more common in recent years, the cause of this is uncertain.
Triggers include specific allergies to foods, overheating, secondary infection, wool next to the skin, cat and dog fur, soaps, detergents, house dust mites and pollen. Extreme hot and cold, humidity, and hormonal changes in women (caused by the menstrual cycle and pregnancy) can also cause a flare-up.
The initial approach to treatment of atopic eczema involves the avoidance of exacerbating factors and hydrating the skin. Exacerbating factors in dermatitis disrupt the skin’s barrier function include excessive bathing, low humidity environments, dry skin, exposure to solvents and detergents and emotional stress. Avoiding these factors is beneficial for acute flare ups and long term management. A sleeping environment with minimal dust and upholstery reduces exposure to house dust mites and may potentially reduce the severity of eczema.
In adults, food allergies do not appear to be a factor in eczema. Using dietary exclusions for long term eczema in a large 2008 study did not improve the condition. In infants, avoidance of certain foods can help. Common food triggers include eggs, nuts, peanut butter, chocolate, milk, seafoods, and soya.
Maintaining adequate skin hydration
Evaporation of water on the skin leads to dry skin in patients with eczema; skin hydration is a key component of their overall management. Lotions, which have a high water and low oil content, can worsen dry skin via evaporation and trigger a flare of the disease. However, thick creams (eg, Eucerin®, Diprobase®) which have a low water content, or ointments (eg, petroleum jelly, Emulsifying Ointment), which have zero water content will better protect against dry skin.
A study in infants with atopic dermatitis who required moderate or high potency topical steroids (see more details later) found that infants treated with emollients had significantly decreased requirements for topical steroids compared with the group of infants who were not treated with emollients. Emollients are best applied immediately after bathing when the skin is well hydrated.
Hydration can be improved by soaking in a bath containing a bath additive such as Oilatum® for 10 to 20 minutes. Bath additives leave the skin and bath very slippy so take particular care when bathing. No well-designed studies have been published to determine whether showering or bathing is preferable in patients with eczema. To reduce microbial resistance, preparations containing anti-bacterials (eg. antibiotic creams) should be avoided except where infection is present or is a frequent problem.
Free Eczema skincare consultation at our Eczema Clinic
Whelehans Pharmacy offer free Eczema skincare consultations at our Eczema Clinic on Saturday July 16th with skincare expert Trish Wallace. Learn how to reduce redness and irritation and how to reduce frequency of flare-ups. Whelehans offer a range of effective products that give clearer skin in a safe and effective way without the need for stronger and potentially damaging prescription medicines like steroid creams. Book your free appointment; call Whelehans at 04493 34591 to discover clearer skin.
More Over the Counter options
In Part 1 I discussed how the initial approach to treatment of atopic eczema involves the avoidance of exacerbating factors and hydrating the skin. Triggers include specific allergies to foods, overheating, secondary infection, wool next to the skin, cat and dog fur, soaps, detergents, house dust mites and pollen.
Urea is a hydrating agent naturally found in many emollients sold over the counter in pharmacies including Calmurid® and Eucerin® cream. It is one of three natural moisturising factors (NMF) in the outer horny layer of our skin. The other two NMFs are lactic acid and amino acids. There are markedly reduced amounts of urea in dry skin conditions.
Urea is strongly hygroscopic (water-loving) and draws and retains water within skin cells. Urea softens the horny layer. Urea can be beneficial in dry skin conditions where scaling and flaking occur and can be useful in elderly patients. It can also be used in conjunction with corticosteroids to enhance to penetration of skin. Whelehans Intensive Moisturising Cream was developed by our pharmacist because brands such as Calmurid® Cream, while effective, are very expensive. Our cream contains 10% urea and is over half the price of brands such as Calmurid® Cream.
The efficacy of preparations containing crotamiton (Eurax®) for itch is uncertain so are best avoided in Eczema. Similarly, calamine lotion is best avoided. Topical doxepin (Xepin cream®: prescription only) is rarely prescribed for itch due to the risk of drowsiness and the stipulation that coverage should be less than 10% of body surface area.
Oral antihistamines are widely used for itch in patients with atopic eczema. The evidence supporting their use is relatively weak since no major studies with definitive conclusions have been performed. However, sedating antihistamines appear to be most effective. There is little evidence to support the use of one sedating antihistamine over the others. The response to different antihistamines varies from patient to patient. Chlorphenamine (Piriton®) is the only sedating antihistamine available over the counter in Ireland. Although not as effective as sedating antihistamines, non-sedating antihistamines such as cetirizine (Zirtek®, Cetrine®) and loratadine (Clarityn®, Lorat®) can be useful where sedation will be an issue. Tepid baths to hydrate and cool the skin can also temporarily relieve itching.
A gem from La Roche Posay
La Roche Posay’s Cicaplast Baume B5® balm is one of the best products for flare ups. It is suitable for everyone, including babies, and will not only help clear up the irritated areas, but also relieve skin from itching. Our pharmacy team recommend it as they find it often delays or prevents the need for subsequent use of stronger prescription medicines like steroid creams. Whelehans health and beauty team find La Roche Posay’s Cicaplast Baume B5® cream not only has excellent healing powers for eczema but also for chapped lips, dry or cracked skin, skin tightness, minor everyday injuries caused by daily aggressions or sensitive and irritated baby skin.
Precription medication options for Eczema
Apart from Hydrodrocortisone 1% Cream (which is also available over the counter from pharmacies after consultation with your pharmacist), all the treatments mentioned in the rest of this article can only be prescribed by a medical professional and must be used under strict supervision from your healthcare professional.
When skin is not inflamed, patients should bathe daily and then immediately apply an emollient. Patients should use the highest oil content emollient ((eg. Emulsifying Ointment). Patients with inflamed skin can be initially treated with topical corticosteroid such as hydrocortosone 1% cream. Consult with your pharmacist or GP before considering these steroid creams or ointments.
The face and skin folds are areas that are at high risk of thinning/marking with corticosteroids. Initial treatment in these areas should start with a low potency steroid such as hydrocortisone 1% cream. A moderate or potent corticosteroid such as clobetasone-Eumovate® (moderate) or betamethasone-Betnovate® (potent) may be needed for more severe cases. Higher potency topical corticosteroids (clobetasol-Dermovate®) can be used for up to 10 days in some patients with severe flares, and then replaced with lower potency preparations until symptoms resolve. Potent steroids are generally avoided on the face and skin folds. However, limited brief use of potent steroids can produce a rapid response after which patients can be switched to a lower potency preparation. This approach is best restricted to supervision by a dermatologist. The British Association of Dermatologists recommends using topical steroids for 10-14 days when eczema is active followed by “holidays” or “breaks” with just emollients.
Topical corticosteroids can be used one or more times daily, however the benefit of using more than once daily is unclear. There is some evidence that the intermittent use of corticosteroids as maintenance can help prevent relapse. Generally, ointments are more effective than creams, as the emollient action and occlusive effect results in better penetration. Ointments also require fewer preservatives so the potential for irritant and allergic reactions is lower.
Eczema: Prescription medication options (Part 2)
Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to firstname.lastname@example.org
Over the last two weeks in the Examiner, I discussed how the initial approach to eczema including avoidance of exacerbating factors and hydrating the skin and steroid use more severe cases. This week I discuss prescription options which may be required for resistant cases.
This is an option only prescribed by specialists. They may be more effective than steroids alone, decrease sleepless nights and prevent admission to hospital. The benefit of using wet wraps in the long term (beyond about four weeks), or in less severe cases are less firmly established. Emollients are applied under a double layer of tubular bandage such as Tubifast®, the innermost of which is wetted with tepid water. Tubifast® garments are an easier alternative to the bandages and can be taken off easier to apply more emollient. When necessary, topical steroids can be applied under the wet wrap, but this form of occlusion will increase both the efficacy and the side-effects of the steroid. The advantage and disadvantages of wet wraps are as follows:
Reduces inflammation, provides a barrier to prevent scratching, reduces water loss, reduces steroid requirement, improves sleep, may reduce admissions to hospital.
Increases steroid absorption and side-effects, training required, commitment and time, may be difficult to get children to co-operate, child may feel too hot or cold, increased infection risk, high cost.
Where the control of dermatitis is resistant to conventional therapy, referral to a dermatologist is necessary. Other treatments including ultraviolet light therapy and immunosuppressants such as methotrexate are restricted to severe cases unresponsive to conventional treatments. For the purpose of this article I will concentrate on conventional therapies only.
Free Eczema skincare consultation at our Eczema Clinic
Whelehans offered free Eczema skincare consultations at our Eczema Clinic last Saturday July 16th with skincare expert Trish Wallace. People learnt how to reduce redness and irritation and how to reduce frequency of flare-ups. Whelehans offer a range of effective products that give clearer skin in a safe and effective way without the need for stronger and potentially damaging prescription medicines like steroid creams. Due to the success and popularity of our Eczema Clinic last Saturday, we are offering you one more chance for a free Eczema skincare consultation. Book your free appointment by calling Whelehans at 04493 34591.
This article is shortened to fit within Newspaper space limits. More detailed information and leaflets is available in Whelehans