DERMATITIS

To speed healing and to prevent relapse of dermatitis, the following guidelines are recommended:

• when hand washing, use a soap substitute and lukewarm water; dry carefully with a clean towel, not forgetting to dry between the fingers.
• as far as possible, avoid direct contact with detergents and other strong cleansing agents; measure the quantity of washing powder and detergents (powder or liquid) according to the manufacturer's instructions, otherwise, they may be too strong; keep the packages clean, to avoid irritation from detergent on the outside
• avoid direct contact with shampoo; if possible, let somebody else wash your hair or wear plastic gloves
• avoid direct contact with metal polish, wax polish, shoe-, floor-, car-, furniture - and window-polishes
• be careful not to get solvents and stain removers such as white spirit, petrol, trichloroethylene, turpentine, and thinners on the skin
• do not peel or squeeze oranges, lemons, or grapefruit with bare hands
• do not apply hair lotion, hair cream, or hair dye with bare hands
• wear gloves in cold weather
• do not wear rings when doing housework
• for washing up, use running water where possible and long-handled brushes
• wear PVC, not rubber gloves; suitable types are Glovlies (obtainable from Robert Dyas) or Sensitive Skin PVC House Gloves (from Boots Chemist); they should not be worn for more than 15 to 20 minutes at a time; if water happens to enter a glove, take them off immediately; turn the gloves inside out, and rinse them under hot water several times a week; sprinkle with talc before they are used again, as they must be completely dry
• thin plastic gloves are useful for tasks involving fine movements
• wear gloves when preparing vegetables
• washing machines and dishwashers are the ideal way to prevent further attacks
• remember that the resistance of the skin is lowered for at least 4 to 5 months after the dermatitis appears completely healed, so continue to follow these instructions

Topical treatment of eczema
Emollients

All eczema patients should receive an emollient to use, both in the bath or shower, and on the skin frequently during the day:
The following are recommended as bath or shower emollients:

• AlphaKeri, 240 ml
• Emulsifying ointment
• Oilatum emollient, 350 ml
• Oilatum Gel for shower, 125 g
• Bath E.45, 150 ml
• Arachis Oil, 500 ml
• Balneum 200 ml
• Emulsiderm 250 ml
• Neutrogena products
• Hydromol, 350 ml
• Unguentum Merck, 200 ml dispenser

Any of the above can also be used as emollients to be applied frequently during the day, but alternative (and perhaps more pleasant) emollients for this purpose are:

• Diprobase cream, 500 grams or 100 grams
• E.45 emollient, 500 g
• Hydromol cream, 500 & 100 grams
• Unguentum Merck, 200 ml
• Alcoderm cream, 60 g cream
• Alcoderm lotion, 120 ml

A rather messy, but extremely good preparation for the very dry skin of bad atopic eczema patient is 50% white soft paraffin/50% liquid paraffin (500 grams).

The regular use of an emollient is more important than the steroid application but is often forgotten. Emollients can make the bath very slippery so it is especially important with the elderly to advise the use of a rubber mat in the bath.

For hand eczema, use aqueous cream or Unguentum Merck in a pump dispenser instead of soap for washing purposes, and suggest a good hand cream to use frequently (e.g. hourly). Neutrogena dermatological hand cream is an excellent example, but any that the patient likes is acceptable.

Topical steroids

With children, emphasise the relative safety of Hydrocortisone Ointment 1%. It does not produce significant atrophy of the skin, even after prolonged use and can be used safely in generous amounts.

Always use ointment bases unless actually weeping. The emollient effect of the ointment base is helpful and the steroid penetrates better from an ointment base.

In the average adult it requires 25 grams of an ointment to cover the body, i.e. 50 grams per day or 350 grams per week. So, even a child with widespread eczema may require 100 grams of Hydrocortisone 1% per week or even more, at least for a short time until the eczema is under control.

The inadequate supply of topical steroid is the single most common complaint we get from patients who are referred from GPs.

Steroid potency
Mildly potent: Group 4

Hydrocortisone 1% is considered to be relatively safe as it does not produce significant skin atrophy. In babies whose body surface in relation to mass is high, and in whom the skin is very permeable, take care to keep the amount of steroid to the minimum, to prevent unwanted systemic effects.

Moderately potent: Group 3

Use any of the following:

• Clobetasone butyrate
• Eumovate
• Flurandrenolone
• Haelan

These are well tolerated even in the long term, but take care on face and in flexures and avoid if possible in infants.

Potent: Group 2

Use any of the following:

• Beclomethasone dipropionate
• Propaderm
• Betamethasone valerate
• Betnovate
• Fluocinolone acetonidev
• Synalar
• Fluocinonide
• Metosyn
• Hydrocortisone butyrate
• Locoid
• Mometasone furoate
• Elocon
• Fluticasone propionate
• Cutivate

(The last four can be used once a day). Do not give any of the Group 2 steroids on a repeat-prescription basis. They all can produce atrophy and striae with prolonged use, and if used over a wide area of the body can be absorbed and produce systemic effects.

Very potent: Group 1

Use either Clobetasol propionate or Dermovate. Dermovate is highly potent and should be used with great care and never given on a repeat-prescription basis. Even the use of 50 grams of Dermovate per week can lead to Cushing's syndrome and cutaneous atrophy can occur within weeks of use.

Potent steroids can be used on a short-term basis for acute eczema or acute flare ups. Many problems are caused by under-use rather than over-use of topical steroid.

Diet

The role of dietary allergens in childhood eczema has been over-emphasised and is no substitute for good emollient use and the use of weak topical steroids. However, some children do benefit from a diet free of cows' milk protein and egg protein, and such a diet can be undertaken for a trial of six weeks in general practice with suitable dietetic advice. Any more extensive diet should be controlled via the dermatology department with access to the dieticians.

Epogam

Epogam contains gamma linoleic acid. There is some theoretical and also experimental evidence that this product can help some children with eczema, and it is certainly worth a try although it is expensive. Give in full recommended doses for 4 months, and if there is no obvious benefit then abandon treatment.

Chinese herbal medicine

There is some evidence from several trials that a Chinese herbal medicine can benefit some children, and indeed adults too, with eczema. The active ingredient is not known and, moreover, there have been reports of hepatotoxicity.

Trials are being conducted at Great Ormond Street Hospital for children, and for adults at the Royal Free Hospital. It has not been possible recently for the Great Ormond Street dermatologists to see patients with atopic eczema when referred by another consultant dermatologist.

The current situation as far as the prescription of traditional Chinese herbal medicine is that Phytopharm Eczema Granules are prescribable on Form FP10 as a special from GPs if the FHSA or fund-holder will pay for it. The cost for an adult for a week's treatment is £68.88p, and an initial treatment of 8 weeks is suggested. It is however, necessary to do regular monitoring of blood count, LFTs, urea and electrolytes. However, this treatment should not be taken lightly and it should be restricted to individuals with severe atopic eczema. It is probably better monitored by a dermatologist. The situation with regard to traditional Chinese medicine is, however, fluid at the present time.

Antihistamines

Non-sedating antihistamines are relatively ineffective in the pruritus of eczema. Consider either Vallergan or Pheneragan. Phenergan is rather short-acting but Vallergan tends to be rather long-acting and may make children feel rather dopey the next day. Atarax can also be used.

Potassium permanganate

Remember the value of Potassium Permanganate soaks for weeping eczema, especially of the hands and feet (in fact a blistering and weeping rash due to fungus or bullous pemphigoid or any other cause can be treated in the same way). Use at a strength of 1 in 10,000. They can be prescribed as Permitabs. Remember to tell the patient that Potassium Permanganate stains, especially nails (nail varnish can be used to prevent staining). Use the soaks twice a day for 10 to 15 minutes each time until the rash has stopped weeping and then stop. This usually takes only a few days. Continuing the soaks once the skin is dry will cause further drying and irritation.

Career advice

It is important that patients who have had atopic eczema, even if now healed, should avoid certain occupations, as they run a high risk of developing a primary irritant hand eczema, e.g.:

• Hairdressing
• Catering
• Nursing
• Engineering
• Car mechanic
• Labouring

It is worth mentioning this to parents of children with eczema, to prevent problems occurring once they are already in training or a job.

Summary

• Do not accept eczema as an adequate diagnosis; treatment hinges on establishing its cause and type.
• Keep strong Group 1 and 2 steroids entirely off the face and skin of infants; monitor repeat prescriptions of Group 1 and Group 2 steroids.
• Do not promise that atopic eczema will be cleared by any particular age; guesses are usually wrong and patients lose faith.
• Give career advice to atopic eczema patients.
• In an acute flare up of constitutional eczema consider:

- Superadded staphylococcal infection often characterised by weeping eczema, folliculitis and pustules; treat with Flucloxacillin or Erythromycin 250 mg qds for five days; topical steroid/antihistamine mixture is usually required
- Eczema Herpeticum; enquire about exposure to the herpes simplex virus; clinically, small regular vesicular or ulcerated lesions occur in groups; the patient is usually systemically unwell and may require admission; treat with Acyclovir 200 mg orally five times a day for five days in patients not severe enough to require admission