management guide for the pharmacist€¦ · management guide for the pharmacist A concise guide on the management of the common skin condition ECZEMA This guide has been prepared

eczema management guide for the pharmacist

1300 300 182 www.eczema.org.au

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www.eczema.org.au 1300 300 182

eczema

management guide for the pharmacist

A concise guide on the management of the common skin condition ECZEMA

This guide has been prepared as a resource guide for pharmacists on behalf of the

Eczema Association of Australasia Inc.

The Eczema Association of Australasia Inc is a support network for eczema patients

and their families. They provide support and education to try and help improve the

quality of life to sufferers and their families.

The guide has been written by pharmacist, Tina Aspres and reviewed by a

Dermatologist, Dr Phillip Artemi. Tina Aspres and Dr Phillip Artemi have also co-

authored the book “All About Kids’ Skin – The Essential Guide for Parents” (ABC

Books 2008).

The information in this guide should not be relied upon to provide or be a substitute

for medical advice, diagnosis, treatments or other decisions. It is merely a general

guide and appropriate referral to a dermatologist or medical practitioner should be

made for confirmation of the condition.

© Tina Aspres and Dr Phillip Artemi 2009

All rights reserved. No part of this guide may be reproduced, stored in a retrieval system or

transmitted in any form or by means, electronic, mechanical, photocopying, recording or otherwise,

without the prior written permission from the author.

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What is eczema?

Eczema is a general term that is used to describe inflammation of the skin.

The most common type of eczema is atopic dermatitis. The terms ‘eczema’ and

‘dermatitis’ are interchangeable as they both refer to inflammation of the skin.

There are various types of eczema. In this guide, eczema refers to atopic dermatitis.

Eczema is a very commonly occurring, chronic, non-contagious, itchy, inflammatory

skin condition characterised by flares and remission. It usually commences in early

childhood (the first year of life), with over 90% of cases in children having occurred

by the age of 5. However eczema can occur in people of any age1.

Eczema is attributed to both genetic and environmental factors that result in a

breakdown in the skin barrier2. The skin barrier’s role is to provide a protective

mechanism to the body from the environment, prevent penetration of irritants and

allergens and loss of water through the skin.

Evidence has shown that a defective skin barrier is one of the main causes of

eczema. A compromised skin barrier makes skin vulnerable to external insults,

causing it to react abnormally to various triggers that would not necessarily affect

others with an intact skin barrier. Eczema sufferers have sensitive skin.

It is estimated that 15-20% of children3,4 and 2-10% of adults suffer with eczema and

up to 85% of cases in children will resolve by adolescence. Eczema usually improves

with time, but not all children will grow out of it.

With some it may even worsen during adolescence or in adult life. Even in those that

resolve, the skin will usually remain sensitive.

The prevalence of eczema appears to be increasing, especially in developed

countries. This increase has been attributed to, or rationalized by, the ‘hygiene

hypothesis theory’ that attributes the propensity of atopic disease to living in a

‘cleaner’ environment and having reduced microbial exposure in early life5,6.

Although eczema is not considered a serious or life threatening medical condition, it

can have a significant effect on the patient’s psychological and social well-being,

as well as a negative impact on the quality of life for both the patient and their

family. A recent study of parents comparing impairment of quality of life in children

with skin disease and children with other chronic childhood diseases supported the

view that skin disease had a similar impact on quality of life as asthma, diabetes,

enuresis and cystic fibrosis7.

Many eczema patients are affected by the stigma associated with the visibility and

appearance of the condition.

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Eczema can be intensely itchy, causing sleep disturbances and irritability in the

patient. Itching in a child causing sleep disturbances can also have an impact on

the entire family1,8.

What are the various types of eczema?

o Atopic eczema

o Irritant contact eczema

o Allergic contact eczema

o Seborrhoeic dermatitis

o Nappy dermatitis

o Discoid eczema

o Chronic hand eczema

o Pompholyx

o Varicose eczema

o Asteototic eczema

What is the role of the pharmacist in eczema management?

Skin hygiene and daily treatment of skin dryness are necessary measures to help

patients improve their quality of life and possibly reduce the frequency of flares.

The pharmacist plays an integral role in the identification, treatment and

management of eczema. The public routinely consults pharmacists for advice and

treatment of skin rashes well before they see their doctor. They look to the

pharmacist for help in identifying the rash, for information and advice on

management and treatment options of the condition. Many of these skin rashes are

usually eczema, with the predominant feature they present with being dry skin.

The successful control and management of eczema is multifactorial. The

pharmacist can assist in helping the patient, children and their parents, achieve

their goals and minimise the occurrence of flares by educating the patient on the

condition, helping patients identify triggers and advise on minimizing or eliminating

exposure to them, helping them make any lifestyle changes that may improve

exposure to triggers, advising on an appropriate skin care regimen, of which

moisturizers play a crucial role in the maintenance and management of the

condition. In addition, they can educate the patient on the correct use of

prescribed medication, especially regarding corticosteroid use (where there is

much misinformation and steroid phobia) and alleviate their fears regarding use

and reinforce the aims of treatment to provide maximum benefit and minimum side

effects.

In order to provide the best possible advice and care to eczema patients,

pharmacists should provide both verbal and written information. This will help

reinforce the treatment management plan and help improve patient compliance.

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Although there is no cure, eczema can be treated and successfully managed to

prolong remission and minimise flares. Early intervention is crucial to reduce the

potential for acute flares and to minimise the need for pharmacological

intervention.

The role of the Pharmacist is to help patients achieve a reduction in eczema flares

with education and advice and reinforce what the doctor has discussed with them

during their consultation.

The main aim is to try and help the patient improve their quality of life.

In summary, Pharmacists can:

1. Help patients recognise the symptoms of eczema promptly so that

appropriate treatment can be commenced

2. Help patients identify triggers

3. Advise on removal of, or avoidance of triggers. Early intervention will help

decrease the severity and frequency of flares

4. Advise and educate patients on correct use of prescribed medication

5. Advise patients on appropriate skin care

6. Help reduce dryness and itch. Moisturizers should form the basis of routine

treatments and skincare regimes. Advise patients on the important role

moisturizers have in the maintenance of eczema as they help to repair and

restore skin barrier

7. Educate patients on how to control and regulate their eczema, how to

identify a flare and have an action plan in place that can be implemented

as soon as a flare occurs

8. Help educate patient to recognise the signs and symptoms of a bacterial or

other type of infection (weeping, oozing, crusting, papules, pustules, no

response to treatment after 2 weeks, worsening of the condition despite

treatment, fever, malaise)

9. Refer to doctor if diagnosis is not known

10. Refer to doctor if patient is not responding to treatment after two weeks or

condition worsens with treatment.

Regarding prescribed medication, the pharmacist should ensure the patient clearly

understands the following:

o Name of what the patient is to use or what has been prescribed

o What it is being used for (eg for moisturization or inflammation-

flare)

o How much to use

o How often to use

o When to use

o How long to use each product for

o Reinforce that topical steroids are only to be used for the short

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term and are not to be used long term

o Ensure that there is an understanding that moisturization should be

used daily and long-term, and continue even when using other

prescribed topical treatments.

Features that help in the identification of eczema:

There are no laboratory tests to diagnose eczema. Diagnosis is based on the clinical

features of the condition:

Skin is dry, may be scaly and/or flaky in appearance

Pruritus (often intense itch present)

Inflammation – pink to red patches present

Skin may be red and hot

Skin has a rough texture and lacks lustre

Skin may be cracked and leathery in appearance due to the persistent

scratching

Cracks and fissures may be present in the skin (may bleed) due to skin

dryness

May be painful

Blisters may be present

Skin may weep or ooze and crusting may be evident

Be aware that not all eczema presents in the same way. There will be

different manifestations of the condition between sufferers

Triggers that have been associated with an increased

incidence or worsening of atopic eczema include:

Contact allergens

o Fragrances (Common fragrance allergens are: eugenol, isoeugenol,

geraniol, cinnamic acid, hydroxycitronellal, oak moss substitute, balsam

of peru, coumarin, cloves, cinnamon, sandalwood, wood tars, cassia

oil)

o Preservatives (in cosmetic and personal care products) (eg

formaldehyde, quaternium 15, methylchloroisothiazolinone, diazolidinyl

urea, imidazolidinyl urea, isothazoline mixes, paraben mixes, thiomersal)

o Soaps and detergents, shampoos, bath gels, shower gels and other skin

care and cosmetic products

o Hair dyes (paraphenylenediamine)

o Antiperspirants/deodorants

o Fabric (eg: wool and synthetic fabrics, shoes, socks)

o Plants (eg: grevillea, rhus tree, privet, chrysanthemum)

o Metals (eg: nickel in costume jewellery, buckles, zips)

o Rubber and latex (gloves, footwear, watchbands)

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o Sand

o Disinfectants (eg: isopropyl alcohol, chlorine, nitriles)

o Chromium and chromates (in leather, paints, cement, shoes)

Environmental and Inhaled allergens (usually seasonal and often associated

with allergic rhinitis and/or asthma. Often affect the face, especially around

the eye area.) The prevalence of eczema has increased two-to-three fold over the

past 50 years9. Research shows the increase is linked to a range of environmental

factors8.

o House dust mite

o Animal dander (pets: cats, dogs, birds)

o Grass and pollens (also seasonal)

o Moulds

o Clean homes

o More affluent families

Food allergens

o Cow’s milk

o Eggs

o Peanuts and tree nuts

o Wheat and soya

o Fish and shellfish

Seasonal: A change of seasons can trigger eczema ‘flare up’. Skin’s

susceptibility to irritants and allergens is enhanced due to its increased

tendency of dryness. Cold and dry weather, with low humidity can

exacerbate dry skin10,11. Research has shown more than half of those with

eczema believe that their flares are worse in spring8.

o Extremes of temperature – low temperature

o Humidity - low

o Tobacco smoke

o Higher incidence is seen in affluent families

Genetics:

o Genetic predisposition (other family members suffer with the condition

and or +/- asthma and allergic rhinitis [hay fever])

Occupation: it has been estimated that approximately 30% of people will be

affected with their occupational choice as a result of eczema12. Examples of

occupations with a higher probability of being affected include:

o Hairdressers

o Cleaners

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o Rubber, chemicals and textile workers

o Mechanics

o Chefs

o Builders

o Woodworkers

Microbial agents:

o Staph. aureus

o Viral infections (herpes)

o Fungal infections:

Pityrosporum

Candida

Treatment of eczema:

A stepped approach is used in the treatment and management of eczema. Any

pharmacological management plan is tailored specifically to the needs of each

individual patient based on the severity of their symptoms and their age and the

site on the body affected.

Moisturizers should form the basis of any eczema management plan. Patients need

to be educated on the importance of them being incorporated in a daily skin care

regime, regardless of whether the condition is present or not. Untreated and

uncontrolled eczema can progress to chronic persistent disease.

Understanding Moisturizers:

– An integral and essential part of any Eczema Management Plan

Skin dryness is a major cause of itch in eczema. This leads to the scratch-itch-scratch

cycle, which leads to a compromise of the skin barrier, often causing breaks in the

skin. A defective skin barrier gives way to infection and penetration of irritants and

allergens. Due to a better understanding in skin barrier function, moisturizers have an

important therapeutic role in the successful management of eczema.

Pharmacists are able to help patients manage the symptoms of dry skin; itchiness

and flakiness by helping patients restore and maintain the integrity of the skin barrier

function with the appropriate use of moisturizers.

Moisturizers are one of the most underused treatments in eczema management13.

They are an essential part of the management for all dry skin conditions (especially

eczema) by providing hydration to the skin. Moisturizers work by providing a

protective layer over the skin to help keep moisture in and allergens and irritants

out.

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Moisturizers are a crucial adjunct to pharmacological treatments, and will help

reduce the need of topical corticosteroids14.

What is a moisturizer?

Moisturizers help restore the defective skin barrier and are the mainstay of the

treatment of eczema.

There are essentially three main components to a moisturizer:

An occlusive to prevent the loss of water from the skin

Creates a barrier of the skin

Are usually greasy (eg petrolatum, lanolin, mineral oil)

A humectant to attract moisture towards the skin

Enhance water absorption from the dermis to the epidermis

Attract water from the surrounding environment

Eg: glycerin, hyaluronic acid, propylene glycol, urea, sodium and

ammonium lactate, honey

An emollient which soothes dry skin and improves its appearance

Eg: dimethicone, isopropyl myristate, isopropyl isostearate

Are moisturizers effective in treating eczema?

Yes – absolutely.

For mild eczema and many cases of moderate eczema, moisturizers combined with

general skin care measures can be successful as a treatment14. Even when

prescription medicine is required, moisturizers must continue to be used to obtain

maximum benefit.

Good eczema control is not possible without regular use of moisturizer.

Why are moisturizers important in eczema treatment?

Eczema skin is dry skin. As already discussed, eczema skin has an impaired barrier

function. This results in the skin being unable to retain water in and irritants and

allergens out. This culminates in the typical eczema patches to appear on the skin.

These patches can be red, crusty, scaly, flaky, oozing and intensely itchy.

Moisturizer, when applied regularly, will soothe, hydrate, protect the skin and relieve

the itch.

Moisturizers are underused in eczema skin – they should be used daily and applied

liberally!!

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People often perceive moisturizers to be “inactive” and do not understand why

they are so important in controlling eczema15. When used correctly in a daily skin

care regime, moisturizers become effective “active” treatments.

Moisturizer treatment is not just about products but understanding how and when to

use them to get maximum benefit.

Applying moisturizer to the body several times a day is time consuming, tedious and

an inconvenient task for many, so people are inclined to under use them because

of this.

Lotions, creams or ointments?

Lotions contain more water and fewer oils than creams and so they spread easily

when applied. They act quickly and are useful for hairy areas of skin but overall they

are not very effective in moisturizing dry skin.

Creams contain a mixture of water and oils and like lotions feel light and spread

easily when applied to the skin. They too need to be reapplied often, as they do not

penetrate very dry skin readily.

Creams and lotions are ideal for weeping eczema and daytime use. Due to their

higher water content, they contain preservatives to prevent microbial

contamination of the product. Sometimes they may be irritating and may cause

stinging or burning on application.

Ointments do not contain water (or only a very small amount) and as a result tend

to be thick and greasy. Some people find them cosmetically unacceptable. They

are ideal for very dry and thickened skin and are ideal for nighttime use.

What are the key features to look for when choosing a moisturizer

There is no one ideal moisturizer that is guaranteed to be universally acceptable to

all patients. Choosing an appropriate moisturizer is often based on trial and error to

find one specifically acceptable to a patient. Everyone will have different likes and

dislikes, and ones not irritating to some may prove to be irritating to others. In

general, the list below will help as a guide when choosing a moisturizer for a patient.

Fragrance free product

Ideally with a pH around 5.5

Avoid “cosmetic moisturizers” which may contain sunscreen, perfume,

antioxidants, anti-aging or herbal ingredients and other chemicals which

could be problematic

If possible, a patient should try the moisturizer on a small test area first for a

few weeks to make sure it does not sting, burn or irritate the skin

It should be affordable because it needs to used several times a day

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Should be aesthetically pleasing and cosmetically acceptable to the patient

or else they will not be used properly (eg too greasy)

When and how to apply moisturizer

Should be used liberally and frequently – every hour or two if the skin is very

dry, or at least three times a day

Apply gently (never rub up and down vigorously)

It is best to apply moisturizer after bathing or showering whilst skin is still damp

(within 3 minutes), while water is still trapped in the skin. This will help lock in

the moisture

Remind patients to continue to use the moisturizer, even when the eczema

patches have improved or cleared. This will help prevent the frequency and

severity of flares

When used in conjunction with prescribed treatments, each product should

be applied separately, allowing several minutes in between each application

Soap free washes:

Skin cleansing is important to maintain an appropriate level of hygiene however,

care must be exercised to ensure that cleansing products used are appropriate

and not likely to cause further damage to an already compromised skin barrier.

Soaps often cause skin dryness and irritation, which may worsen an already sensitive

skin. Water should be tepid – not hot, and showering or bathing should be short.

Baths are preferable to showers, but not always practical.

There are essentially three categories of cleansing agents:

Soaps (pH usually 9-10)

Surfactants – soap free (usually have a range of pH)

Surfactant-free cleansing agents – oils / products containing mild emulsifiers

to enhance cleaning properties

The irritancy potential of a cleansing agent is based on the type and concentration

of surfactant within a product.

The ideal cleanser is a soap free cleanser made up of mild synthetic surfactants.

There is no ideal cleanser that is irritant free for everyone. Choosing a soap free

cleanser is based on trial and error until one that suits the patient is found.

Bath oils may also be used in the bath or shower; however, fragrant and aromatic

oils should be avoided due to their higher incidence of irritancy and allergenicity.

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Topical Corticosteroids:

Topical steroids play an important role in bringing the management of eczema

under control. Using the correct potency as prescribed, for short-term therapy will

help the patient gain maximum benefit with a minimum chance of any adverse

reactions.

Topical corticosteroids are prescribed by a general practitioner or dermatologist

and will be tailored to a patient’s individual needs and site of use. They are used in

short, sharp bursts to bring flares under control. They should only be applied to

affected areas of skin and not on eczema clear skin. Potency is not related to

concentration.

Generally, as a guide, mild potency topical corticosteroids are used on the face for

3 to 5 days and mild to high potency corticosteroids are used on the body for 7 to

14 days. Prescribers may differ slightly to what has been stated above.

Corticosteroids are usually applied once or twice daily.

Instruction labels should be placed on the tube and not on the outer packaging.

Pharmacist should ensure that patients understand that corticosteroids are not to

be used on a continuous, ongoing basis, but only for the time period specified by

their doctor and for flares when they occur.

Moisturizers and corticosteroids may be applied on top of each other, although

there is no rule as to what should be applied first or second. It is however, advised

that several minutes should lapse between each application of topical product.

Corticosteroids should not be applied if a viral infection of the skin is suspected.

Patients should be referred to their dermatologist for diagnosis and treatment if a

viral bacterial infection is suspected.

Adverse effects of topical corticosteroids:

Treatment failure with topical corticosteroids usually results due to steroid phobia

and patient anxiety about potential side effects because patients do not

understand their use.

Adverse drug reactions to corticosteroids usually occur:

In infants and children from prolonged use

Use of high potency steroids long-term or in the wrong site

When used over a large surface area

When used under occlusion (penetration is increased) for prolonged periods

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Common adverse skin reactions16:

Skin atrophy

Striae

Telangiectasia

Folliculitis

Acneform eruptions

Hypertrichosis/hirsutism

Delay wound healing

Secondary bacterial infection/masking or aggravation of existing bacterial

infection

Masking of fungal infection

Table 117,18:

Potency of topical corticosteroids

Topical immunomodulators/calcineurin inhibitors:

Pimecrolimus (Elidel 1%) and tacrolimus (compounded) are new topical therapies in

the treatment of eczema that have shown to have certain benefits whencompared

to mild corticosteroids19.

Potency

Generic corticosteroid

Mild Hydrocortisone 0.5% to 1%

Hydrocortisone acetate 0.5% to 1%

Moderate Triamcinolone acetonide 0.02%

Betamethasone valerate 0.02% and 0.05%

Desonide 0.05%

Potent Betamethasone diprionate 0.05%

Betamethasone valerate 0.1%

Methylprednisolone aceponate 0.1%

Mometasone furoate 0.1%

Very potent Betamethasone diprionate 0.05% in optimized vehicle

NB: It is important to reinforce to a patient they understand that topical corticosteroids

are not to be used on eczema clear skin for maintenance. General skin care measures

(particularly use of moisturisers) are the mainstay to prolonging remission.

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They are immunosuppressants of the calcineurin inhibitor class10 and help reduce

inflammation, thus reducing pruritus. Their long-term safety profile has not been

established as they have only been available for a short period of time. They have

been indirectly associated with an increased incidence of skin cancer formation

and lymphoma in those treated with the medication, however, a conclusive direct

link has yet to be established.

Their use is intended for intermittent, short-term treatment of facial atopic dermatitis

where topical corticosteroids are contraindicated or have failed to adequately

control the condition. Pimecrolimus has PBS listing for use in patients 3 months and

over. Maximum period for use in adult patients is 6 weeks20.

There are additional precautions for use in babies and children. For infants 3 months

to 2 years of age, the topical treatment should be applied to the smallest affected

area of skin and for no longer than 3 weeks per flare.

Contraindications and precautions20:

The pharmacist’s role is to ensure the patient adheres to and understands the use of

these medications to minimise adverse effects and maximize treatment outcome.

The pharmacist should advise the patient to:

only apply this medication to active areas of disease (NOT to disease clear

skin)

avoid sun exposure and apply sunscreen after the application of

pimecrolimus

not use the treatment if they are having phototherapy

not apply pimecrolimus to vaccination sites

Not be used by patients immunosuppressed or taking immunosuppressant

medication

Not be applied to areas where skin cancers have been removed

Not to be applied to areas affected by premalignant change (eg actinic

keratoses)

be applied to areas of active eczema.

Not use this topical treatment under occlusion.

Should not be used by pregnant women and with caution in breastfeeding

women.

Application of multiple topicals:

All topical applications should be applied one a time – with several minutes

(approximately 10 minutes) wait in between each application. There are no rules or

preferences as to which product should be applied first. Some Dermatologists

recommend applying topical steroid first and then the moisturizer, whilst others

believe applying a moisturizer first and then the topical corticosteroid.

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Antibiotics:

Oral antibiotics are used for secondary infection. Secondary infection is usually due

to skin being broken by scratching, further compromising the skin barrier. This gives

way to penetration of bacteria, virus or fungus. A doctor or dermatologist will

prescribe antibiotics if an infection is evident.

Infection is usually due to staph. aureus, however, herpes infection and other

bacterial or viral infection may also occur. If this occurs, appropriate antivirals and

antifungals will be prescribed. Any patient suspected of having any type of

infection should be referred for appropriate diagnosis and commencement of

treatment.

Topical antibiotics should not be used long-term because of the risk of developing

resistance.

Antihistamines:

Antihistamines are largely ineffective for pruritus of atopic dermatitis and should not

be used routinely in eczema management3,21. However, non-sedating

antihistamines (although some may cause sedation) are worth trialling for severe

itch where the itch exceeds the degree of atopic dermatitis present and may also

provide some benefit to those suffering with allergic rhinitis22. Sedating

antihistamines are useful to patients experiencing sleep disturbance due to the itch.

Topical antihistamines are not effective to treat itch in eczema.

Complimentary/alternative therapies:

Although popular, many complimentary and alternative therapies, (homeopathy

and herbal medicines) have not been fully evaluated in clinical studies to support

their use in the treatment and management of eczema. There are safety and

toxicity issues that also need to be considered.

Given the concern that many patients have regarding corticosteroid use, it should

be highlighted that not all natural therapies are safe and some may even be toxic.

One must remember that natural does not always mean safe. Often there is no or

very little quality control with the preparation of these treatments, no

standardization of doses of some herbal remedies which may be made up into a

tea and include a recipe of ten or more herbs23 and topical preparations may be

contaminated and even have corticosteroids added to them.

Furthermore, certain Chinese herbal medicines have been known to cause liver

toxicity and even renal failure23. Caution and care should be advised to patients

seeking alternative practitioners and ensure they are reputable and registered to

practice.

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Patients should also be advised to inform their doctor if they elect to introduce any

type of complimentary or alternative therapy to their treatment regimen.

Food supplements:

There have been some promising results that have been observed in studies with

various food supplements - predominantly evening primrose oil, fish oils, oils rich in

gamma linoleic acid and probiotics. However, there is still no conclusive or

confirmed evidence of their effectiveness due to the variability in results seen. Some

patients find a remarkable improvement in eczema whilst others find no change

whatsoever.

Probiotics:

Children with atopic dermatitis have more coliforms and clostridia and less

bifidobacteria and lactobacilli in their gut flora than not atopic dermatitis sufferers.

This cause caused interest in probiotics as a preventative treatment of atopic

dermatitis. There have been several studies that have shown a benefit in prevention

of atopic dermatitis, however, there have been many other studies that have failed

to support this. Whilst a small number of studies may have suggested that probiotics

may be useful as a preventative measure in atopic dermatitis, they have not

proven to be of benefit for the treatment of atopic dermatitis24.

Manuka Honey:

Honey has been used in remedies for wounds since ancient times. One particular

type of honey from New Zealand - manuka (Leptospermum spp) - has shown to

have enhanced antibacterial activity. The antibacterial effect is labeled with its

UMF (Unique Manuka Factor) according to Waikato University's honey research unit

tests.

This particular honey is thought to have anti-inflammatory activity that stimulates

immune responses and this is how it may provide some relief for eczema sufferers. It

was predominantly developed for wound care and has been shown to have some

effect on staph aureus, which is the predominant bacteria on the skin in eczema.

A patch test should be carried out before used to ensure there is no irritant or

allergic reaction.

Dressings:

The use of wet and dry dressings increases the potency of the topical treatments

and is best managed by a Dermatologist.

Dry dressings: are crepe or tube bandages that are applied over an ointment to

keep it in place.

17


Wet dressings: are applied over a prescribed topical corticosteroid. The topical

steroid (usually a cream) is applied to the skin then a tube or crepe bandage that

has been immersed in warm water (water squeezed out) is applied over the

medication, and this is followed by a dry bandage on top.

The wet dressing is usually removed after an hour and moisturiser is then applied

over the affected area.

Table 2:

Treatment options

Mild eczema

Moderate eczema

Severe eczema

Moisturiser

Mild potency topical

corticosteroid

Moisturiser

Mild to moderate potency

topical corticosteroid

Topical pimecrolimus

Dry dressings

Moisturiser

Moderate to potent

topical corticosteroids

Topical pimecrolimus

Wet dressings

Phototherapy

Systemic therapy

Allergy assessment:

Generally, allergy testing is not routine or required for eczema patients. Allergy

assessment is useful in those patients where topical therapies in combination with

general skin measures have failed to provide an adequate response and where a

particular allergen is suspected.

Eczema and cosmetics:

Cosmetics are renowned for causing irritation in those with sensitive skin as well as

those with not so sensitive skin. Adverse reactions are common with topical

preparations, and virtually anything applied to skin has the potential to cause an

allergic reaction or irritation.

Irritation usually occurs as soon as (or soon after) a product is applied to the skin.

18


Common signs of irritation include sensations of burning, stinging, itching, redness,

inflammation and soreness.

Fragrances added to a product are usually the main culprits of irritation or allergic

reaction, followed by preservatives and then other ingredients.

Fragranced free preparations are usually labeled as being hypoallergenic.

Hypoallergenic products are less likely to contain irritating or common sensitizing

ingredients, however, they do not guarantee to be allergy or irritant free and can

still be irritating or cause an allergic reaction, so patients should be warned.

Any patient experiencing an irritation with any topical product or cosmetic applied

to the skin should be advised to discontinue use immediately.

Compliance:

Understanding the treatment and management of eczema is crucial to ensure the

condition does not flare regularly. Helping patients adhere to daily moisturiser use is

the key to the successful management of eczema.

Non-compliance of treatment and management is usually attributed to patient fear

of side effects of topical corticosteroid use due to their lack of understanding about

this medication.

Other contributing factors are the products used are not aesthetically pleasing to

ensure patient compliance, and side effects from other treatments applied by the

patient eg stinging, burning or itching sensation has led to discontinuation of use.

Furthermore, patients find daily application of moisturiser all over their body tedious

and time consuming and opt not to do it.

19


Conclusion:

Pharmacists are ideally placed to help educate patients on eczema and its

management.

The role of the pharmacist in the management of eczema is crucial to the patient

achieving the best possible outcome with their therapeutic treatment and

maintenance regime.

It is the pharmacist’s role to:

educate patients on eczema and how to recognize and identify common

symptoms

identify flares and have a management plan that can be implemented

quickly to manage the flares

educate patients on the importance of skin hygiene

educate patients on the important role moisturisers have in the management

of eczema, reinforce the importance of their regular, continuous use daily,

even when the skin is clear of disease, to ensure the skin barrier can be

maintained in the best condition possible

help patients be compliant with their medication use and treatment regime

educate patients in the correct use of topical corticosteroids and

immunomodulators

allay patient fears of corticosteroid use. Corticosteroid topical therapy is safe

if implemented correctly

help patients recognize triggers and offer strategies to eliminate or minimise

exposure to triggers

advise on lifestyle changes that can be made to help improve the quality of

life

inform them that the Eczema Association of Australasia Inc can be

contacted for help. It is a support network for eczema patients and their

families. They understand eczema as they are eczema sufferers themselves or

have family members with the condition. Having an understanding of

eczema, they are committed to providing help and support to sufferers to

help improve their quality of life.

For further information, visit www.eczema.org.au or call 1300 300 182.

http://www.eczema.org.au/

20


References:

1 Eczema Association of Australasia Inc. Membership Survey 2003. 2 Kisich, K.O, et al. J. Allergy Clin. Immunol. 122(1):62-8 3 Buys, L. Treatment options for atopic dermatitis. Am. Fam. Phys. 2007; 75:1-8 4 Leung, DYM., Bieder, T. Atopic dermatitis. Lancet 2003; 361:151-60 5 Mar, A & Marks, R. The descriptive epidemiology of atopic dermatitis in the community, Aust. J. of

Dermatol,1999: 40, 75-76. 6 Kalliomaki, M. Lancet 2001; 357:1076-79 7 Beattie, P. E. and Lewis-Jones, M.S. A comparative study of impairment of quality of life in children with skin

disease and children with other chronic childhood diseases. Br. J. Dermatol. 155, 145-151 (2006) 8 Department of Dermatology, St Vincent’s Hospital Melbourne. Atopic Eczema Health Survey, January 1999 –

February 2000, sample size 85 9 Mar, A & Marks, R. The descriptive epidemiology of atopic dermatitis in the community, Australasian Journal

of Dermatology, 1999: 40, 75-76. 10 Denda, M., Sato J., Tsuchiya, T., Elias, P.M. and Feingold, K.R. Low humidity stimulates epidermal DNA

synthesis and amplifies the hyperproliferative response to barrier disruption: implication for seasonal exacerbations of inflammatory dermatoses. J. Invest. Dermatol. 111, 873-878 (1998)

11 Sato, J., Denda, M., Nakanishi, J. and Konyama, J. Dry condition affects desquamation of stratum corneum in

vivo. J. Dermatol. Sci 18, 163-169 (1998) 12 Holm, E.A., Esmann, S. and Jemec, G.B. The handicap caused by atopic dermatitis – sick leave and job

avoidance. J. Eur. Acad. Dermatol. Venerol. 20, 255-259 (2006) 13 Reid, P. and Lewis-Jones M.S. Sleep difficulties and their management in preschoolers with atopic eczema.

Clin. Exp. Dermatol. 20, 38-41 (1995) 14 Lucky, A.W., Leach, A.D., Laskarzewski, P. and Wenck H. Use of an emollient as a steroid sparing agent in the

treatment of mild to moderate atopic dermatitis in children, Pediatr. Dermatol. 14, 321-324 (1997) 15 Elias, P.M., Wood, L.C. and Feingold K.R. Epidermal pathogenesis of inflammatory dermatoses. Am J. of

Contact Dermat. 10, 119-126 (1999) 16 Wolvedton, SE. Comprehensive Dermatol. Drug Therapy. Philadelphia: WB Saunders(2001) 17 Therapeutic Guidelines: Dermatology. Version 2 (2004) 18 Rossi S, ed. Aust Medicines Handbook 2006. Adelaide: Australian Medicines Handbook Pty Ltd 2006 19 Garside, R., Stein, K., Castelnuovo, E., Pitt, M., Ashcroft, D., Dimmock, P. and Payne, L. The effectiveness and

cost effectiveness of pimecrolimus and tacrolimus for atopic eczema: a systematic review and economic evaluation. Health Technol. Assess. 9. iii, xi-xiii, 1-230 (2005)

20 Novartis Pharmaceuticals Australia. Elidel Product Information. 27 July 2006 21 Sidbury, R., Hanifin, JM., Systemic therapy of atopic dermatitis. Clinical. Exp. Dermatol. 2000; 25: 559-66 22 Dohil, MA., Eichenfield, LF., A treatment approach for atopic dermatitis. Paed. Ann. 2005; 54:201-23

23 Harper, B. Traditional Chinese medicine for eczema. BMJ. 1994; 308: 489-90

24 Prescott, SL., Bjorksten, B. Probiotics for the prevention or treatment of allergic diseases. J. Allergy Clin.

Immunol. 2007; 120: 255-62.

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Notes:

Documents

management guide for the pharmacist€¦ · management guide for the pharmacist A concise guide on the management of the common skin condition ECZEMA This guide has been prepared