Different types of treatment
This part of the book is divided into sections describing the different approaches to eczema treatment. It starts with the most important rule – avoiding things that make eczema worse.
For some people, following these rules will mean that they need no medical treatments at all and never visit a doctor about their eczema. For those who still need medical treatments, avoiding exacerbating factors will reduce the amount of medical treatments that they need and so reduce the likelihood of side effects from treatment.
Avoiding things that make eczema worse
One of the most important aspects of managing eczema is to avoid things that aggravate the skin. Some of these things, like soap and water, are predictable and affect most people with eczema; others are unpredictable and affect only some people. Factors in the latter category may change with time and are identified after a period of trial, error and close observation.
Soap, shower gel, bubble bath and water
One of the problems with eczema is that the skin is a less effective barrier than it should be. Washing can make this worse by removing the protective oils that the skin naturally produces. These oils help keep the skin soft and supple – like polish on your shoes. When they are removed the skin is prone to dryness and cracking.
The oils are already reduced in eczema. Water, soap and bubble bath are all designed to remove them further, which makes things worse. Water alone acts as a solvent and, although skin oils are not very soluble in water, they can still be removed to some extent. People tend to use more soap in a hard water area because there is less lather.
But even without soap, it seems that hard water can irritate the skin more than soft water. Some people have found that fitting a water softener helps, but this is expensive with no guaranteed benefit. It may be worth noting the effects of different water types when visiting relatives or on holiday, before making the investment.
So how can I stay clean?
Most people, and especially babies, don’t get very dirty. You can stay clean by using substitutes for soap and water. Some adults prefer to use limited soap in the groin and armpits.
Creams and lotions
You can use an emollient cream or ointment as a substitute for soap by taking a small scoop of it into the hand and rubbing it directly onto the wet skin before rinsing off. It will remove all surface dirt and leave a protective layer of moisturiser on the skin.
Liquid forms of moisturiser or lotion are also designed for use in the bath or shower. These are watered down moisturiser and, although they are convenient, it may be cheaper to use normal moisturiser.
Many bath products that claim to be gentle can still cause trouble. The simple test is if the product leaves the skin feeling greasy it is doing a good job. If it doesn’t, it may be removing skin oils you need.
Standard bath oils for eczema will probably pass the test of leaving the skin greasy. Other oils often work satisfactorily, although the fragrance in strongly scented ones may irritate the skin.
Bathe less often
You do not need to bathe every day. It may be necessary to clean the skin if there is ooze and a tendency to infection, but if the problem is just dry itchy eczema, it is fine to use plenty of moisturiser and skip some baths.
Excessive cleanliness may increase the tendency to acquire eczema in childhood. For this reason, perhaps a few missed baths is a good thing.
Heat usually makes itching worse, unless it comes from the direct effect of sunshine on the skin. Working in a hot office, sitting in a hot schoolroom or sleeping in a hot bedroom are all likely to make itching worse.
Itching leads to scratching. This in turn makes the skin itch more once the immediate relief of scratching has passed.
Further itch results in continued scratching, which makes the eczema worse. This process is known as the itch–scratch cycle.
During the day, babies should be dressed in a manner that allows flexibility, with easy removal of layers when going from cool to warm environments. Look for the coolest place in a room, away from the fire, radiator or other source of heat. Adults should under-dress to keep a little cool.
Keeping children cool at night
Itching and scratching are a common problem at night. Babies in particular can’t tell you how hot they are. It is tempting to wrap them up warmly which may make them overheat and itch.
Simple things to do are:
• Make sure the bedtime bath is not too hot. If they come out of the bath looking flushed, they cannot cool off properly once you have covered them in cream, clothing and bedclothes, and are likely to overheat early in the night.
• Pat the skin dry and avoid vigorous rubbing with a towel.
• Give them time to cool off after a bath before applying the evening treatment.
• Use only cotton pyjamas/baby grows. All-in-one night-clothes make scratching when half asleep less easy.
• Use cotton sheets and separate layers of non-wool blankets to allow flexibility with the amount of bedding. A duvet will either be on or off.
• Keep the bedroom cool. This usually means having the central heating off and sometimes a window open.
• Check they are not too hot when you go to bed and if you get up in the night.
• Avoid having them in your bed to avoid them getting hot from your body and bedding.
Dogs, cats, horses, donkeys
These four animals are the ones that most commonly cause problems. However, if you are thinking of getting a pet, it might be best to borrow one for a week, whatever the species, to assess how the eczema (or asthma) responds.
What causes the problem?
The protein from the fur and saliva of these animals often provokes a reaction in those with atopic eczema and can also trigger asthma or hay fever. When the animal protein comes into contact with skin, redness and itch may develop. This starts the itch–scratch cycle and the eczema gets worse.
A typical episode occurs when your child strokes a dog then rubs his or her eyelids, which become puffy, red and itchy. The skin may become blotchy elsewhere and then the child starts to scratch.
Can the problem be avoided?
Unfortunately, the proteins that cause the itch may remain even when the animals are not there. An atopic child going to the house of someone with animals may have a marked reaction even if the animals are out at the time.
Animals that are kept out of doors all the time and never allowed in the house may be less of a problem. However, their protein may be present on the hands or clothes of other family members.
How should I deal with the problem?
There are enough chance encounters during the first few years that you will learn which types of animal provoke a reaction. The tendency to react can get either better or worse with time.
Usually, repeated exposure will tend to make it worse, but a child may become insensitive if in no contact with the type of animal in question for several years. It is wise to ensure that children have only very limited contact with any animals until you are happy that they do not have an adverse reaction.
Do we need to get rid of the family pet?
This question most often crops up in the second year of life, when the diagnosis is clear and eczema is bad and persistent enough to make the question important. The decision whether to keep pets can be difficult.
If your child shows a clear reaction after contact with the pet, there is little doubt that the pet is contributing to the eczema. You may have to take the drastic step of letting go of a family pet.
If there is no distinct reaction to the pet, but the eczema is bad and you want to do anything that might help, try closely observing the effect of your child’s playing with the pet for an afternoon. Does it lead to increased itching or possibly sneezing or wheeze?
If there is no clear answer, try a separation period when your child and the pet do not share any rooms and effectively live in different parts of the house. Try limiting your pet to the downstairs if you live in a house. See if things get better, then try a period of playing again to see if things get worse.
Whatever the effect your pet has on your child’s eczema, the pet should be kept out of the child’s bedroom. This is because even a small level of reaction will become significant if the child is exposed to the pet’s protein for 8 or 10 hours at a time.
Can we safely get a pet?
This question may be answered by contact with the pets of friends. But not all dog hair is the same.
The Royal Society for Prevention of Cruelty to Animals runs a scheme whereby, if you want one of the pets in their care, it is possible to meet, stroke and possibly walk a pet that you hope to have. This should give some indication of whether the pet is safe for you, but it is no guarantee.
Household dust is likely to contain remnants of house-dust mite, a very small creature that sheds protein into the environment. House-dust mite can be found on dusty surfaces and in carpets and soft furnishings, including beds. Children with eczema commonly react to this mite with increased itch, sneezing and wheeze.
Controlling the house-dust mite
House-dust mite can be tackled by routine measures to minimise dust in the house. The bedroom is the most important place to start as your child spends a significant amount of time here:
• Avoid deep pile or old carpets and dusty soft furnishings. Ideally have linoleum, plastic or stripped floors.
• Make sure that bedding is non-wool, non-feather and reasonably new.
• Wash the bedding regularly in a cycle at 60 degrees to kill mites and their eggs, and to clear allergenic proteins
• Mites and their eggs can also be killed by freezing. If you need to cleanse a soft toy, it may be easier to put the toy in the freezer for a day than to wash it.
• The bed and mattress should not contain horse hair and ideally should also be fairly new.
• The pillow should be filled with synthetic fibre, rather than feathers.
• A plastic cover on the mattress may reduce the amount of dust coming out of the bed.
• Clean flat surfaces, for example, shelves, window sill, chest of drawers with a damp cloth to mop up dust.
• Some specialist cloths claim to trap dust when still dry, which if effective could make cleaning easier (Swiffer cloths: www.swiffer.com).
• Vacuum the room regularly.
More specialised techniques for trying to remove all traces of the mite, largely from the bedroom, include mite-killing sprays, which are available from chemists and some pet stores, high-power vacuum cleaners and bedding covers. Reducing the amount of house-dust mite in the bedroom, however, does not necessarily result in improved skin.
Some studies suggest that expensive Gore-Tex bed covers, used in combination with a high-suction vacuum cleaner and insecticide, can improve atopic eczema. Cheaper plastic covers also work, but may be less comfortable to sleep on. It seems that cotton is not as good, although there is some controversy.
Food and diet
In spite of intense interest in this area, no clear relationship between food and eczema has yet been established. However, there is no doubt that, for some children, avoiding certain foods does make a difference. Working out which foods are relevant is often difficult. Suspect foods will often be part of other items, especially manufactured foods.
Sometimes the effect of certain foods can be seen within a few hours. Often the food causes a blotchy redness that itches. This provokes scratching which leads to a general deterioration in the eczema. Less noticeable reactions may only become evident by the improvement seen after a period of avoidance.
The foods most likely to cause problems in atopic eczema include:
• cows’ milk and its products
• legumes, such as peas, soya and beans
• other nuts to a lesser extent.
Can changes in diet help?
A range of studies suggests that, if avoidance of cows’ milk products is going to make a difference to a child’s eczema, this will probably be in the first 18 months of life. However, the experience of individuals suggests that diet does sometimes make a difference after the age of 18 months.
Usually, these individuals stand out because there is a clear history. Parents report such events as: ‘whenever he eats cheese he goes bright red and starts scratching’, or ‘she just puts a peanut in her mouth and her lips swell up’.
An exclusion diet is one that has no trace of one or more of the foods in question. It is difficult to follow even for a limited period, and carries the risk of undernourishment. It is generally recommended that people undertaking exclusion diets do so only with the help of a dietitian.
How a dietitian can help
A dietitian will ensure that you have truly excluded the foods in question. You will also be reassured that dietary requirements are met by compensating with other appropriate foods.
The dietitian will also help you understand how to re-introduce foods into the diet. This is usually done at intervals of three to seven days so any slow reactions can be picked up before you move on to re-introducing the next food.
Will an exclusion diet help?
The overall benefits of exclusion diets are often difficult to work out, particularly in the long term. In one study involving a group of children with severe eczema who followed a strict exclusion diet, after 12 months there was no obvious benefit in those who had stuck to the diet.
When there are definite accounts to guide the family, there is little problem in justifying an exclusion diet. However, in the absence of a good history, there are seldom examples of a marked response.
Mothers’ diet during pregnancy
A recent review published scientific literature on whether dairy products during pregnancy affect the likelihood or severity of eczema in the baby. The authors conclude that adding the data from different trials provides information on the outcome of 334 women and their babies. Avoiding dairy products did not alter the incidence of eczema but had an adverse effect in reducing the birthweight of the baby.
Mothers’ diet during breast-feeding
It is uncertain whether a mother’s intake of cows’ milk and egg products can influence her child’s eczema by passing into the breast milk. The results of one study suggest that avoidance of cows’ milk products and eggs by breast-feeding mothers may help some children, especially if there is a strong family history of eczema.
Recent studies have suggested that a probiotic diet supplement during pregnancy and breast-feeding may reduce eczema in your offspring.
Infant feeding and weaning
There is some evidence that babies who are weaned onto solids later have less of a problem with eczema than those started sooner. Although the evidence is not strong, it is best not to hurry starting solids. Babies who are weaned late are less likely to encounter foods that may make eczema worse at an early age.
Continuing to breast-feed
Continuing to breast-feed may help to affect the severity of eczema, but the evidence for this is only weak. A recent study of over 7,000 children in Bristol suggested that breast-feeding had no beneficial effects on the skin of children with eczema. Your decision whether to continue will be influenced by factors such as ease of breast-feeding, severity of eczema, experience with other children and family history of eczema.
Alternatives to cows’ milk
Soya and goats’ milk are used as alternatives to cows’ milk, but allergies may also develop to these types of milk. Around 10 per cent of babies who have problems with cows’ milk also develop soya protein allergy. It is questionable whether goats’ milk is suitable for the gut of a baby aged under six months.
Hydrolysate formulas can be given to infants and children. They are preparations of cows’ milk in which the protein has been broken down into a form that doesn’t provoke reactions in those with cows’ milk allergy.
The full range of fat, carbohydrate, minerals and vitamins remains in the milk. These formulas are available at chemists and on prescription.
They could be part of a supervised diet for a trial period. In general, hydrolysate formulas are the best alternative to cows’ milk if a long-term substitute is needed.
Processed foods may contain additives to prolong shelf-life and enhance their colour and taste. Additives are normally listed on the pack.
The role of additives in eczema is not clear. Individuals who are convinced that an agent such as tartrazine is a trigger often do not react on taking a test dose.
However, some additives may affect some people some of the time. Those most commonly suspected are azo dyes (food colourings) and benzoate preservatives (food preservatives), which usually come under the category of an E number.
Avoidance of foods containing these additives may help if more fresh produce is included in the diet instead.
Infection with bacteria or with viruses can play a big part in the deterioration of eczema.
Bacteria are micro-organisms that multiply and spread between people by a variety of means. They typically provoke redness and possibly pus in patches, which may be hot, tender and swollen.
Viruses are not living in their own right. They are small bundles of genetic material, deoxyribonucleic acid (DNA) or ribonucleic acid (RNA), that invade cells. They proceed to use the machinery of the cell they invade to multiply and go on to invade other cells.
The areas of concern are skin infections, rather than other infections or even illnesses associated with rashes, such as chickenpox. There is no apparent extra risk with fungal infections.
Where you have eczema, the skin is more likely to be cracked and there may be ooze or crust. These factors promote bacterial infection. Infection then contributes to the itch and deterioration of the eczema, leading to a cycle of infection and re-infection that can be difficult to break.
The relevant bacteria are Staphylococcus aureus and Streptococcus species. These bacteria are found scattered on everyone’s skin but more often in people with eczema.
They may be more commonly found up the nostrils, in the warm creases such as armpits and groin and also at the back of the throat. Ninety per cent (nine out of ten) of children with eczema carry staphylococci on their skin most of the time compared with less than a third of children without eczema. All people may carry the bacteria without showing any signs of infection.
Preventing infection is a valuable part of avoiding factors that make eczema worse. It is difficult to prevent contact with all sources of bacteria. However, it may be possible to avoid contact with people with a heavy load of bacteria, such as those with infected skin wounds or infected broken skin on the hands, or another child at school with impetigo.
The signs of bacterial infection include:
• rapid increase in the area of eczema
• increased itch
• golden crusts and ooze
• increased redness and itch
• certain types of infection that may make you feel unwell and feverish.
The main treatment for bacterial infection of eczema requires a combined approach. First, antibacterial medication to clear the infection and, later, steroid creams or ointment to improve the eczema.
How can I avoid repeated bacterial infection?
Reinfection of eczema is a frequent and difficult problem. Try to identify possible sources of bacteria that could be reinfecting the skin and treat or avoid them.
The bacteria could come from a family member, school friend or other close contact, from another site on your child’s body, or from an old contaminated pot of treatment. Pots of treatment that are past their expiry date or have had dirty fingers put in them may act as sources of bacteria that can then be spread on the skin with treatment.
The most common source of bacteria is an area of broken skin or impetigo. Another possibility is warm, moist body sites – particularly inside the nose – which act as a reservoir of infection.
Bacteria can survive up the nose even after a course of antibiotics by mouth. The best way to get rid of the bacteria is with a course of antibiotic ointment applied up the nose.
Ask your doctor about swabbing inside your child’s nose to see if there are significant bacteria in the nose. If the problem persists, ask about swabbing other family members – the bacteria may be passing from them to the person with eczema, causing further infection after each course of treatment.
Repeated infection may also occur because bacteria are resistant to the antibiotics used. Bacterial resistance means that bacteria have developed new ways of reacting to a particular antibiotic so it is no longer deadly to them.
Bacterial resistance is detected by swabbing the infected skin with a small swab of cotton wool on a stick, and sending the swab to a laboratory for examination. The lab report will identify the bacteria and specify the antibiotics that will kill them.
Often, there is neither any obvious source of infection nor any bacterial resistance. In this situation, the tendency for re-infection may lie with the skin rather than the bacteria.
Re-infection is likely if the skin remains broken and weeping, as a result of continued itch, scratching and active eczema. You may need to use more intensive eczema treatment during and immediately after the period of infection as well as maintaining antibacterial treatment.
Meticillin-resistant Staphylococcus aureus – MRSA
This is a name that has become infamous in the UK and is used by some as an indicator of cleanliness in hospitals, but is now also often found in the community. MRSA is usually no more dangerous than other forms of Staphylococcus aureus, but it is resistant to the usual antibiotics so that it is difficult to cure an infection with routine treatment.
If your eczema becomes infected with MRSA, it may settle to a limited extent only when treated with your normal antibiotics. Typical treatment will require a combination of one or more oral antibiotics, antiseptic in the bath and an antiseptic detergent to wash the skin with.
You should also have swabs taken from your nose to see whether the bacterium is found there. If present, it is treated by a further antibiotic ointment up the nose. Once the course of treatment is completed, the skin should be swabbed again in order to determine whether the treatment has been effective.
Herpes simplex virus (cold sores)
Cold sores are tender, tingling spots that usually crop up on the lip. They are caused by infection with the herpes simplex virus and occur as small blisters or pus spots, either singly or in a cluster.
Most people who suffer from them become familiar with the tingling that often starts 24 to 48 hours before any obvious spot.
The virus lives in the roots of the nerves, following an initial infection in infancy or childhood. The virus multiplies and comes to the surface at different times such as:
• certain times in the menstrual cycle
• in connection with bright sunshine
• during illness or when you are feeling generally run down, such as after a bad chest infection.
When the spots are fresh they shed herpes virus which can cause problems for people with eczema. Herpes infection in someone with active eczema can result in the rapid spread of small blisters or pustules over wide areas of the body. The sufferer may feel generally unwell on top of the skin discomfort.
This pattern of herpes infection is called eczema herpeticum. Although it is most common in children, it can also happen in adults. Most parents who see it in their child, or most adults who suffer an episode, will recognise it as something more aggressive and rapidly changing than normal infected eczema.
Eczema herpeticum needs treatment with oral or intravenous antiviral drugs in most cases. Intravenous treatment requires admission to hospital so that a thin cannula, or tube, can be placed in a vein to provide regular doses of treatment.
Take care to prevent contact between those with cold sores and those with eczema. Be wary if anyone in your family gets cold sores. Treat them early with antiviral creams (for example, aciclovir) available over the counter.
If cold sores occur frequently, keep antiviral cream in the fridge so it is available for use at the first opportunity, when the site begins to tingle. Early treatment reduces the life of the cold sore and the period during which virus is shed. Herpes virus from genital herpes can also cause problems and the same precautions should be taken.
People with eczema may also develop cold sores and, if they are frequent, you may need to discuss early or preventive oral antiviral treatment with your doctor. Oral therapy is more effective than cream, but may have more non-specific side effects, requires a prescription, may promote viral resistance if used too much and is more expensive.
This is a very common viral skin infection that is spread by close contact. The typical appearance is of small pearly bumps on the skin, often with a small dimple on top.
It seldom causes itch or pain. The infection usually disappears within 6 to 18 months when immunity develops.
Children with atopic eczema get attacks of molluscum which are sometimes more widespread than average and particularly affect the areas with eczema, namely the flexures of the elbows, behind the knees and in the groin. At these sites, the eczema deteriorates, which promotes scratching and spread of the molluscum.
There is no good treatment for molluscum, although many things can be tried. The treatments have various drawbacks, including pain, scarring and spread of the virus.
Given that infection eventually settles, the most common view in the UK is that it is better to wait for immunity to develop than to interfere medically. For patients with eczema, extra skin care and active eczema treatment may be necessary at the involved sites.
This may include occlusion with bandages if scratching and spread are a major problem. You do not have to keep your child home from school, but it may be reasonable to keep separate towels. When the molluscum settles there may be small pitted scars for some time – even years.
Changes may be noticed in the skin during periods of exceptional stress, and certain kinds of stress are likely to contribute to eczema in some people. In adults, changes are commonly associated with significant life events such as marriage, moving house and bereavement.
Conversely, the relief from stress experienced on holiday can have positive effects on skin. Stress is difficult to define, however, and changes in stress may be connected with many factors.
Eczema and occupation
People who still have atopic eczema in their teens may need to consider career choices carefully. The emphasis is to avoid anything that is likely to make the skin worse.
In general, jobs with a large manual or wet component, such as catering, cleaning, hairdressing and building, are likely to cause problems. Jobs that involve mainly paperwork, information technology or talking are less likely to cause trouble.
People with eczema often seek help, particularly for hand problems. Individuals with atopic eczema who develop skin problems in one of these occupations may wonder whether they are having a predictable exacerbation of their condition, or whether they have developed some form of allergy.
Testing for allergic contact dermatitis is often undertaken even though the problem is really caused by irritant substances, such as water and solvents, rather than any specific allergy.
The appeal of discovering an allergy is that, once a specific agent is identified and removed from the workplace, the eczema will settle down and the person can continue with the same job. Failure to find such a substance, however, means that the person either has to make significant changes in work practices or has to change his or her job entirely.
Passive smoking is bad for eczema. This has been described in published studies.
A smoky atmosphere may make the skin more reactive than usual, and eczema may get worse. Individuals with atopic eczema may also have a tendency to develop asthma and there is a clear connection between worsening asthma and exposure to cigarette smoke.
Topical treatments for eczema: ointments, creams and oils
Specific treatment for eczema depends on how bad the eczema is. It also depends on how much you want to bring it under control.
For some people, even a small amount of rash is unacceptable and they will invest much time in ensuring that it is suppressed. Others will tolerate quite marked eczema because either they do not find it a major problem or they dislike using treatments so much that they prefer to keep the rash.
Many traditional medical treatments for eczema are available ‘over the counter’ (OTC). This means that they are available from the pharmacist without a prescription. The pharmacist will be able to offer guidance about the condition being treated and the medication in question.
Hydrocortisone is in this category, whereas bath oils and emollients would be available in pharmacies and supermarkets, and no advice would be routinely offered. When medication is available in this form it is said to be licensed as a GSL or general sales list product.
Products that require a prescription from a doctor are referred to as POMs or prescription-only medications. For mild eczema you may want to visit the chemist and try some OTC preparations without involving your doctor.
If you are buying a treatment without a prescription, those sold under a proprietary brand name are usually more expensive than generic (non-branded) products. Generic treatments such as emulsifying ointment often have the term BP after their name, which shows that they meet the standards of the British Pharmacopoeia.
Pharmacists can give helpful advice, although they are not trained in diagnosis of skin disorders and will need to rely on your description of the problem. Be careful of products that you can buy by mail order from newspapers or on the internet.
These may contain products not known to your doctor, undeclared quantities of steroid, or other ingredients that have side effects. Look for established names and reasonable prices, and talk to your doctor if in any doubt.
All products should carry some information. OTC products may list only the product ingredients, although many also contain a patient information leaflet, especially if they are proprietary.
When medication is prescribed, you should also receive information from your doctor and/or a patient information leaflet within the package. Patient information leaflets are often very complete and almost have the format of a legal document.
This tendency means they may over-emphasise side effects, which leads to unnecessary concern. It is wise to read the leaflets, but always discuss any concerns with your doctor. Do not discard the medication on the basis of the leaflet alone.
All medicines should be kept in a safe place. Steroids and medication taken by mouth should be kept out of reach of children or locked up.
Some treatments for eczema should be accessible for regular use and in the reach of children. Keep several pots or tubes of emollient in the home, in obvious places such as the bathroom, kitchen and bedroom, plus a spare one in the medicine cupboard – when you need to use this, you know it is time to get some more.
Over a period of years you may build up a collection of unfinished tubes and pots. It is often worth keeping these in the short term because the intensity of eczema treatment varies, and you may need to return to a treatment that you had discontinued a few months before. Try storing them in old ice-cream containers according to the type of treatment they represent, so you know what you have in stock.
Most products expire and have a date stamped on the ridge at the bottom of the tube or somewhere on the pot or bottle. After this date, the quality of the product is not guaranteed.
Warm or cold storage?
In general, it is wise to keep medication cool, away from radiators and direct sunshine. However, with thick emollient, such as emulsifying ointment, it may be helpful to keep some in a warmer place, or to warm a small amount on the radiator before use.
This makes it softer and easier to spread on. The drawback is that skin may itch as a result of the warmth of the ointment.
Alternatively, where itch is more troublesome than dryness, a cream can be kept in the fridge. Because cool cream can be soothing it can be helpful if you need to rub on something to relieve intense itching, for example, during the night.
Types of treatment
Most treatments for eczema are either topical (rubbed directly on to the skin) or oral (taken by mouth).
Using topical (skin application) therapies
When using any topical therapy:
• Apply it gently.
• Rub mainly in the direction of the hairs on a limb. This is less important or obvious in a baby, but applying against the line of hairs in an adult may block the skin pores, which may provoke pus spots (folliculitis).
• Apply when the skin is at room temperature.
• If using over a large body area, apply in a room without furnishings that may be vulnerable to grease stains.
Emollient is a term given to a range of skin treatments that work by forming a waterproof film on the skin while lubricating the epidermis and increasing suppleness. Some specialists distinguish emollients, moisturisers and humectants. The last two are creams that may provide a source of water, which is actively given to the skin.
These distinctions are not helpful in general terms. All the products can be covered under the heading of emollient and help to:
• relieve itch
• reduce dryness
• reduce cracking of skin
• provide protection against other materials such as water or solvents
• reduce loss of body fluid from broken skin.
Unlike most other eczema treatments, there are no ‘chemically active’ ingredients in pure emollient, so it can be used in vast quantities and in all age groups. Although side effects are possible, these are always short term and usually connected with a physical effect of the emollient rather than any chemical response.
For instance, some people notice that their skin itches more after applying emollient. This is more likely with a heavy ointment that reduces sweating, especially if applied directly after a hot bath or shower.
If you do encounter a problem, try to find a way around it rather than give up on emollient therapy, because it is central to all eczema care and is the safest long-term treatment available. If an emollient seems not to work, you may be using too little and it may help to apply it more often.
If skin remains dry in spite of using more emollient, try using a thicker and greasier version. Once you have identified an emollient regime that suits, use it to help keep your skin in good condition and avoid more complicated treatments.
Quantity of emollient
It is often unclear how much emollient you should be using and there is a tendency to use too little.
The types of emollient
The main types of emollient are:
• emulsifying ointment
• aqueous cream BP
• soft paraffin and liquid paraffin waxes.
Emulsifying ointment BP
A mix of emulsifying wax, white soft paraffin and liquid paraffin which works by forming a waterproof film on the skin while lubricating the epidermis and increasing suppleness. Extremely safe – do not be put off by the term ‘paraffin’ – it is not flammable.
It is a heavy emollient that is very good for dry skin prone to cracking, especially hand eczema. It can cause itch when applied because of thickness, which reduces sweating, and can make fingers greasy so they leave fingerprints on paper.
Aqueous cream BP
Emulsifying ointment (see above) mixed in the factory with freshly boiled water producing a lighter preparation, which is soothing if itch is more of a problem than cracking. It is useful during the day because the lighter nature of aqueous cream makes it less likely than emulsifying ointment to leave greasy marks on paper.
Some people experience stinging when using aqueous cream. This is usually a brief sensation and does not indicate allergy to the cream. However, it may be a reason to try alternatives if they prove more comfortable to use.
Soft paraffin and liquid paraffin mixes
White soft paraffin or yellow soft paraffin can be used separately or mixed with liquid paraffin in various proportions to give a soft and greasy moisturiser. This is a very heavy emollient, most suitable for extremely dry skin, where sweating is not a problem.
It is best used at night. A higher proportion of soft paraffin makes the emollient firmer.
These are mainly proprietary products that cost more than the BP emollients, but are useful to try in case they are more suitable for you. Some contain different major ingredients.
Some emollients work as a barrier cream or ointment and are particularly useful for nappy rash or other sites where urine or faeces irritate the skin or on pressure sores. Examples include: zinc oxide cream BP, zinc oxide ointment BP and zinc oxide and castor oil ointment BP, Conotrane, Drapolene, Metanium, Siopel, Sudocrem and Vasogen.
Minor ingredients of emollients
Many emollients and bath additives contain ingredients that have an antimicrobial or antiseptic effect. Antimicrobials discourage bacteria but do not provide a cure for infection, and the bacteria may still remain after their use. They are useful for recurrent skin infections.
Products containing antimicrobials include the Dermol range of bath additives and creams, Oilatum Plus and Emulsiderm liquid emulsion, which can be added to the bath or used on wet skin.
Other minor ingredients may provide different qualities. Lauromacrogol, which may help relieve itch, is found in E45 itch relief cream and in Balneum Plus.
Oatmeal is a traditional emollient agent that is added in small amounts to Aveeno cream. Oats can also be used in a muslin bag suspended in the bath water, making the bath milky and soft. This is thought to contribute to the skin softening and anti-itch properties of the product.
There is some controversy over the value of bathing, how long you should bathe and the best additives. The following are generally accepted points on bath time:
• Make sure that the water is not too hot because heat encourages itching, especially after bathing.
• Add an emollient to the bath water in generous quantities.
• When there is obvious infection, ooze or crusting, it may help to add additional antiseptic according to instructions from the doctor or pharmacist.
• Avoid soap, bubble bath or shower gel. Use an emollient soap substitute instead and rub gently onto the skin.
• Try changing the containers of the bath emollient to the kind of containers used by commercial suppliers of normal bath products. Many bubble bath liquids come in toy animals or other fun objects. If you transfer the medicated oils into these, it can make your child feel less left out.
Wash hair as seldom as possible, compatible with hygiene. Conditioner may be used as a substitute for shampoo, particularly when there is scalp eczema. In children, it is reasonable to use water alone.
When there is only moderate eczema, which does not involve the scalp, use a mild shampoo separately from bath time, or at the very end of a short bath, when there has not been too much emollient used in the bath. Take care in rinsing the scalp so shampoo does not run down the body or over the face because it may irritate the skin.
If you are an adult with hand eczema, either get someone else to wash your hair or use plastic or rubber gloves.
A bath with lots of emollient can be dangerous because it is very slippery and people of all ages risk falling. Stop children from standing and moving around in the bath and support infants with a firm grip. Adults may need a bath rail. An anti-slip mat in the bath may be of help.
Drying and applying treatments
Baths should probably last no more than 10 to 15 minutes, then dry by patting rather than rubbing, which will provoke itch. After drying is a good time to apply emollient and other skin treatments. Apply these once the body has cooled slightly to avoid sweating under emollient.
If it is very difficult to get emollient on to a baby; it can be easier to apply it to the inside of a babygrow and then put the baby into the prepared garment. This can be messy, but it is much quicker and less traumatic than struggling with a reluctant baby. Some of the emollient will come through if you have applied enough.
Topical treatments for relief of itch
Emollient is one of the best long-term treatments for itchy skin because itch often settles after treating the underlying dryness. Other preparations are also available to relieve itch in the short term. These contain chemically active ingredients, however, which can have side effects.
This is a traditional treatment for itch and can be helpful in the short term, but tends to dry the skin out.
Calamine lotion leaves a powdery residue that dries the skin and may make eczema worse. Calamine oily lotion and calamine in aqueous cream are both preferable for eczema, but not for long-term therapy.
Sometimes used after scabies because it both reduces itch and has a mild anti-scabies action. Rarely used on children under the age of three years. Not recommended if the skin is oozing.
This fairly new cream contains a chemical taken as tablets by people with depression. One of the side effects of the tablets is to reduce itch and this has been exploited by adding the chemical to a cream.
However, the cream can have some of the same side effects as the pills, including drowsiness. The product information also warns of liver problems and difficulty passing urine, although the likelihood of these is very small. Doxepin is not suitable for breast-feeding mothers or young children.
These are not routinely recommended in eczema and are mainly used for short-term itch caused, for example, by insect bites. Long-term use may cause allergy to the product, which will make eczema worse.
How steroids work
The active ingredients of steroid creams and ointments are related to the natural steroids that your body produces. They influence the immune system by reducing the intensity of its actions on the skin. There are at least three ways in which these products can help the skin in eczema:
1 they reduce the inflammation and itch
2 they reduce the redness
3 they are mixed with emollient.
Inflammation and itch
In a condition such as eczema, these steroids reduce the inflammation and itch.
A second action is a short-term effect of causing small blood vessels to contract. This means that the blood supply to the surface of the skin is reduced for a limited period. Given that eczema generally causes the opposite, this is a useful means of reducing the flushing, redness and burning of eczema.
However, if a strong steroid is used long term, the skin may react by overcoming this effect and produce ‘rebound effect’ whereby the skin becomes redder again. This is mainly seen when stronger steroids are used on the face.
The third way in which topical steroids work is as an emollient. When you look at the ingredients of the steroid, the active chemical is often only between 0.5 and 1 per cent of the total content. The rest is some form of emollient.
So with each application of steroid there is a modest application of emollient. This is helpful in that it reduces dryness, reduces evaporation from the skin and increases suppleness.
Side effects of steroids
Other natural effects of these kinds of steroids are that they convert protein into fat and sugar. This is connected to one of the unwanted side effects of topical steroids, where the skin may be made thinner as a result of loss of protein.
Availability of topical steroids
Topical steroids come as creams, ointments, lotions, mousses, gels and scalp liquids. They represent the main advance in eczema treatment over the last 30 years.
In their weakest form they are available over the counter at the chemist and it is up to the individual whether to try them. In the stronger forms, they are available on prescription. This is to help ensure that they are used in the right quantities in the right places for the right amount of time: to hit the correct risk–benefit ratio.
The need for topical steroids depends on factors such as the use of soap or other irritants, how much emollient you use, the severity of symptoms and how well you tolerate them, as well as individual preference. Emollients can substitute for steroid in milder forms of eczema.
Some parts of the body are more likely to suffer steroid side effects than others either because the skin is thinner at these sites or because it is in contact with skin at flexures under the arms, in the groin or between the buttocks. This increases penetration of steroid into the skin, as does covering the steroid with a dressing.
The face is another area where the skin is thin and, if too much steroid is used, eczema may stop improving and the skin may become red and shiny. Every time you try to use less steroid, the skin may flare up again to look even worse than it did before you started treatment.
This happens because the skin has become dependent on the steroid and ‘rebounds’ when you try to stop using it or use a weaker preparation. Although those with atopic eczema need to be careful, this problem is typically seen in young women who have another form of facial eczema.
Topical steroids are divided into four groups, according to their strength or potency:
2. Moderately potent
4. Very potent.
How to use steroid creams and ointments
Steroid creams and ointments must be used in accordance with the manufacturer’s recommendations – thinly and usually twice a day, although this may be reduced according to how well you respond. They should be used in combination with emollients and, if possible, the emollient should be used 20 minutes beforehand.
However, the important step is to get the treatment on the skin and not be too fussy about the order or timing. If the process becomes too complicated, you may be tempted to miss treatments.
What strength of steroid can I use?
The appropriate strength of steroid is determined by:
• the site and severity of the eczema
• the age of the individual
• the presence of any established skin side effects
• the likely duration of treatment.
There is no single answer because it remains a matter of judgement and experience, dependent on the age and site where the steroid is to be applied.
In babies under a year old, use nothing stronger than hydrocortisone 0.5 to 1 per cent at any site. This rule is sometimes broken for short periods to control a flare-up.
Up to the age of 12 it is rare to need more than a moderately potent steroid. If a stronger steroid is used, it should be reserved for limited periods in difficult areas. Armpits, groin and face should be treated with mild steroid.
During this period, the skin becomes thicker and can tolerate stronger steroid creams. Prolonged periods of potent steroid may be needed at some sites, such as the legs and arms, avoiding the armpits and groin. Occasional short periods of very potent steroid may be used in areas of thick skin.
Although a moderately potent steroid may sometimes be needed in skin flexures (for example, armpit and groin), it is still important to use no more than mild steroid on the face unless under close medical supervision. Persistent eczema may change with the seasons, with activities and sometimes for no obvious reason, so there may be prolonged periods of using a potent steroid and then a break. Very potent steroid is rarely needed long term and, when used for more than two to three weeks, it is important to remain aware of the possible side effects described above.
The skin naturally thins as you pass middle age. This increases the absorption of steroid through the skin and increases the chance of side effects.
How much steroid can I use?
There are no fixed rules, only rough guidelines. It may not be necessary to cover an area completely, so the quantities shown are an upper limit. To work out how much you have used, it may be easiest to assess how long you took to use a tube, then judge what you used afterwards. Another way is to weigh the tubes at the beginning and end of the week and calculate the difference.
This is a useful guide to how much you need to buy or when to request a new prescription and should help you see whether you are using enough. There is a tendency to use too little for fear of side effects, in which case you may find your eczema continues to cause you needless trouble.
You need to increase the figure slightly if you are large, or reduce it if you are small. Some people take on adult dimensions sooner than others.
The fingertip measure
This is an alternative way of calculating how much steroid to use. A fingertip unit (FTU) is the amount of cream or ointment squeezed from a tube along an adult index finger from the tip to the first crease.
One FTU equals 0.5 gram and two equals 1 gram. The guidelines for steroid amounts do not apply to emollient, which you should use far more generously and often more than twice a day.
Ingredients added to topical steroids
If eczema is infected, or it is difficult to tell whether an itchy red rash is an infection or simple eczema, a topical steroid combined with an antifungal or antibacterial may be useful. These combined creams are useful short-term treatments (such as two weeks) to overcome infections responsible for a deterioration in eczema.
Many of the names of these creams include the initials of the added ingredient. For example, Betnovate C is the steroid betamethasone valerate mixed with the antibacterial clioquinol.
Alternatively, the name may be the other way round, with the initials of the steroid last, as in Fucidin H, which is the antibiotic fusidic acid combined with the steroid hydrocortisone. Another is Canesten HC, which is the antifungal clotrimazole combined with hydrocortisone.
Some preparations contain three ingredients. Trimovate, for example, contains the steroid clobetasone butyrate, the antibiotic oxytetracycline and nystatin, which is active against yeasts.
In 1984, scientists discovered tacrolimus from a strain of Streptomyces in a soil sample taken from Mount Tsukuba in Japan. Tacrolimus is a drug that has some effects in common with steroids.
Until recently, its main use was as an oral drug for people who had received organ transplants (for example, kidney, liver and heart). In these people it helps suppress the immune system, which would otherwise reject the donated organ. Now the drug is available as an ointment and is licensed for short-term and intermittent long-term use in those with moderate-to-severe atopic eczema.
The terms of the licence state that it is for those in whom ‘the use of alternative, conventional therapies is deemed inadvisable because of potential risks or in the treatment of patients who are not adequately responsive to or intolerant of native, conventional therapies’. The ointment is probably similar in strength to a potent steroid and at present is under patent, so it is sold only as Protopic.
What are the pros and cons of this drug?
It comes in two concentrations, both 0.03 per cent and 0.1 per cent for adults and only 0.03 per cent for children aged 2 to 15 years. If excess is used on large areas of inflamed skin it is possible to suffer toxicity from tacrolimus in the bloodstream.
This would mainly be in the form of raised blood pressure and alteration in kidney function. However, this is not likely in most people and the benefit of the ointment is that it is not likely to cause any thinning of the skin.
Tacrolimus is a prescription-only medication and would rarely be the first choice until the more traditional steroid ointments have been tried. However, where there are fears that the strength of the steroid needed to control the eczema is too great for the body site, or duration of treatment, tacrolimus may be prescribed.
The difficulty lies in deciding who judges this threshold. There is a largely unjustified superstition about steroid ointments that means that people are often afraid of using them.
This may mean that there is pressure to prescribe tacrolimus when it is not necessary and a steroid ointment would do the job well. The most obvious downside of giving all patients with eczema tacrolimus ointment is that it is far more expensive.
However, it also causes a burning sensation or itching when applied, and may increase the chance of some infections. It has not been used under bandages or other occlusion for fear of increasing the amount of absorption into the blood.
For the same reason, it is warned that antibiotic drugs such as erythromycin should be avoided as they can interact with tacrolimus if it is present in the blood. There is limited information that the drug may reduce the threshold for skin cancer and lymphoma long term. Such side effects take many years to become apparent. They are mediated through the immune system, which is suppressed by tacrolimus.
It is for this reason that it is also advised that patients using tacrolimus avoid ‘live’ vaccines. These are immunisations that contain traces of the virus to which you are being immunised and includes measles, mumps, rubella and polio.
Other cautions are to avoid it when having light therapy, and it should also not be used in combination with wet wraps. It may be that the drug finds a particular use in bad eczema on the face and in small children. The caution with the latter is that the ratio of the body surface area to volume in a baby is low – which means that it is easier to absorb significant amounts of a drug into the blood.
For this range of reasons, the prescription of tacrolimus is limited to doctors ‘experienced in the management of eczema’.
Pimecrolimus is prescribed as a one per cent cream and is available only in some parts of the world at present. It has some similarities with tacrolimus, in that it is a non-steroidal anti-inflammatory drug and is roughly equivalent to a moderately potent steroid in effect.
It is derived from ascomycin, a natural substance produced by the fungus called Streptomyces hygroscopicus var. ascomyceticus. It blocks the release of inflammatory chemicals from white blood cells. It is these chemicals that lead to the inflammation, redness and itching associated with eczema.
In trials it appears safe in children and on the face in adults. Where it is licensed, it is limited for use in those aged two years or more.
The side effects are similar to those of tacrolimus. However, it is probably less potent and the effects of ultraviolet light on treated laboratory mice did not lower the threshold for developing skin cancer.
These are used to treat bacterial infection. Different types of antibiotics work differently. All share the principle of interfering with a biological function of the bacteria.
Penicillins prevent the bacteria from making a proper cell wall. This makes the bacterial cells disintegrate.
Erythromycin interferes with production of proteins in the bacterium. In low concentrations, this simply stops the bacteria from producing offspring and the bacteria die of old age. In higher concentrations erythromycin interferes with the bacterial biology sufficiently that it kills the bacteria.
These two effects are the difference between a bacteriostatic and a bactericidal dose, respectively. Bacteriostatic means stopping the bacteria from growing whereas bactericidal means killing them. It can also be the difference between taking the antibiotics at the right times and missing doses.
How are antibiotics taken?
If much of the skin is affected, or the person is unwell, treatment is usually given by mouth, which has the advantage of treating infection at other, less obvious sites. It is also easier and quicker to swallow an antibiotic than to spread it on sore skin. However, antibiotics by mouth can cause side effects such as diarrhoea.
If the affected area is small, or the infection mild, antibiotic creams or ointments applied directly to the skin are usually preferable. These are often mixed with a steroid to combine treatment of the infection and the eczema.
All antibiotics should be used the correct number of times per day in the correct amount, otherwise a partially treated infection may be more difficult to clear. Bacteria may become resistant to antibiotics when they are used frequently or in incomplete courses.
These are a range of chemicals that also play a useful part in treating and preventing infection in eczema. It is important to use appropriate antiseptics in the correct strength. The wrong antiseptic, if too strong, can cause severe soreness or a chemical burn.
How can antiseptics help?
Antiseptics work differently from antibiotics. Instead of altering the biology of the bacterium, they are physically damaging to it. For instance, they may oxidise the bacterial cell wall so that it disintegrates.
Their function does not, however, rely on the biological processes of the bacteria and as a result they do not have the drawback of producing resistant bacteria. Although they can kill or discourage bacteria, they do not provide a cure for infection and bacteria may still remain after their use.
How are antiseptics applied?
Antiseptics cannot be taken by mouth. They are usually applied to the skin as a cream or ointment, or added to a bath or soak so that large areas can be treated.
They may be mixed with bath oils, for the combined effect of treating dryness as well as killing bacteria. They are often mixed with an emollient, which can be used directly on the skin or as a bath additive.
Recent publications have renewed interest in silver as a material that may help treat skin infection. This includes textiles impregnated with silver applied to affected skin and ointments containing colloidal, or other forms, of silver.
Silver-coated textiles are thought to reduce the amount of Staphylococcus aureus on the skin. This in turn avoids the aggravating effects of this bacterium.
Histamine is a chemical produced by the body. In inflammatory diseases, such as eczema, urticaria or infection, large quantities of histamine may be released as part of the body’s own antiseptic and destructive strategies to clear damaging agents from the site of inflammation.
In eczema, we have not been able to work out what benefit the histamine brings. It certainly makes the person suffer and feel itchy. Medications called antihistamines may block its effect.
How are antihistamines taken?
Antihistamines can be taken as liquids or tablets. They fall into two categories:
1 sedating (which make you sleepy)
2 non-sedating (which don’t usually make you sleepy).
A wide range of sedating and non-sedating antihistamines is available both on prescription and over the counter at the pharmacy. Antihistamines are safe if used as licensed.
As a rule, it is most effective to use the sedating antihistamines at night, when they will help you sleep and reduce restlessness. However, they sometimes result in a hangover next day so that you still feel a bit drowsy.
Non-sedating antihistamines are especially helpful for treatment during the day, when you wish to remain alert and may need to do things that require concentration, such as driving, cycling or operating machinery. Some people with eczema also have hay fever, another reason for taking antihistamines, and non-sedating antihistamines are usually preferable for daytime relief.
Even some non-sedating antihistamines can cause mild drowsiness. The patient information leaflet insert will advise whether driving or operating machinery is not recommended.
When antihistamines are necessary for prolonged periods, it helps to rotate different types of antihistamines to avoid a form of tolerance known as tachyphylaxis. This means that the body gets used to the medicine. If antihistamines become part of your routine treatment, or stronger sedating forms are required, it is best to discuss this with your doctor and obtain the medicine on prescription. This may also prove cheaper.
Antihistamines for children
Many antihistamines are available as elixirs (sweet liquids) for children. Sedating ones, such as chlorpheniramine (Piriton), promethazine (Phenergan) and trimeprazine (Vallergan), can be prescribed for use at night.
These are very useful when extra help is needed during a period of difficult eczema, but avoid making a habit of using sedating antihistamines. They sometimes fail to make children drowsy or make them too drowsy, so that they are still sleepy the next day.
If taken every evening, long term, they tend to become less effective. It also means that there is no extra help at hand when you need to deal with a flare-up. Antihistamines are rarely used in children under two years of age, although chlorpheniramine may be used in those slightly younger.
Oral steroids (prednisolone)
During periods of bad eczema it may be helpful to take short courses of steroid by mouth as a liquid or tablets. Oral steroids work by suppressing the immune system and are prescribed by your doctor.
Usually, a course of oral steroid lasts between one and four weeks and may be started in combination with an antibiotic. The steroid course may be tailed off at the end with small doses reduced over a further few weeks.
This helps to ensure that the eczema doesn’t flare up as soon as treatment is stopped. While stopping steroid tablets, make every effort to use other skin treatments regularly to maintain the benefits achieved.
Normally, ‘long term’ means a period of more than two to three months but, if steroids are used beyond three weeks, some of the long-term side effects described below should be considered. If you are not reducing your steroids within three weeks of starting, you might carry a steroid treatment card.
Short-term side effects
In the short run, steroid tablets produce few side effects and all are reversible. These include:
• Increased appetite
• Weight gain – partly the result of eating more and partly of retaining extra fluid
• Change of mood in which, typically, the person becomes more active and feels that he or she has more energy; this can disturb sleep so it is often advised to take the tablets in the morning
• Diabetes mellitus in which the level of glucose sugar in the blood rises; this makes the person very thirsty so he or she drinks more fluid and passes large amounts of urine; it is a rare short-term problem and mainly occurs in people who are likely to develop diabetes
• Indigestion is an occasional problem and should be brought to the attention of your doctor; some tablets have an ‘enteric coating’ which delays disintegration of the tablet in the stomach and helps to prevent indigestion.
Long-term side effects
Some people with bad eczema, or a combination of bad eczema and asthma, need to take steroids longer term; this makes them prone to short-term effects and some additional longer-term effects:
• Weight gain of a particular pattern may be seen, with fat building up around the middle of the body and the arms and legs becoming thin; the cheeks also become fuller.
• The skin may become thin and fragile which, in elderly people, adds to the effects of ageing. The skin bruises easily.
• Blood pressure may rise. This is apparent only when measured and not noted by the person taking steroids. However, it contributes to the future risk of heart disease and stroke, and needs to be monitored.
• The risk of diabetes mellitus is probably greater on long-term steroids, although the doses are usually smaller than in short-term courses.
• Protein and minerals may be lost from the bones, leading to osteoporosis (brittle bones). This usually affects the spine and hips.
• Dramatic loss of body steroids if steroid tablets are stopped suddenly, without gradually reducing the dose. Natural steroids are normally produced by the body in the adrenal glands but, on long-term steroid tablets, the body stops producing them. Symptoms include faintness, feeling washed out or even collapse. This problem is most commonly seen when someone:
– loses the steroid tablets and doesn’t immediately get replacements
– stops the steroids without discussion with a doctor
– becomes ill and forgets to take the steroids.
• During serious illness, such as a bad chest infection, the body is under strain and normally reacts by producing more of its own natural steroids. On long-term steroids, the body is not able to do this and as a result becomes relatively deficient in steroids, in spite of the tablets. Extra doses of steroid are therefore needed during some illnesses.
• Some infections, particularly fungal ones, can be made worse by steroids, so extra anti-infective treatment may be needed. Other infections, such as some bacterial ones, may be less obvious than usual because the body cannot react to them as normal, which may delay proper treatment.
• Chickenpox may be far more aggressive in people taking steroids. Contact your doctor straight away if you think that you have been exposed to chickenpox or shingles. If you have had chickenpox in the past, you will be immune and not considered at risk.
• Courses of oral steroids given to children over many years can reduce their growth.
Keeping side effects to a minimum
If you are on long-term steroids, the following approaches can help keep side effects to a minimum.
Watch your diet and take plenty of gentle exercise. This will help keep your weight and your blood pressure down.
Regular exercise will also help maintain the strength of your bones. Avoid smoking and excess alcohol, which can make osteoporosis worse.
Some medications help avoid the development of osteoporosis. Examples include calcium supplements, a group of drugs called bisphosphonates, oestrogen replacement therapy in women and testosterone replacement therapy in men.
Usually these drugs are used only in older patients, who are at greatest risk of fractures from osteoporosis. Raised blood pressure or blood sugar that develops during steroid treatment is initially treated with diet and exercise, but can be treated with medication if necessary.
At the beginning and during prolonged treatment, measurements should be taken of weight, blood pressure and sugar (glucose) level in the urine or blood.
Azathioprine is a tablet medication that prevents the immune system attacking your skin and allows the eczema to settle down, but it is not often used. It has some benefits similar to oral steroids, but is less immediate and dramatic in its effects.
It is used only when long-term medication is necessary and, unlike steroids, is not used for short courses when rapid results are needed. Some people do not like the medication from the outset whereas others benefit from it for years, with no problems. This probably reflects differences in metabolism, which in part can be checked for by preliminary blood tests.
The main problems are liver upsets, nausea and, more seriously, bone marrow suppression. This last side effect reduces the number of blood cells produced by the marrow and can lead to anaemia and infection.
Although these side effects are very rare, the health of the bone marrow and liver need to be monitored by regular blood tests. Monitoring is of great importance and someone taking azathioprine must always seek medical advice if he or she feels uncharacteristically unwell.
People can be screened to make sure that they are likely to be safe on the drug. This entails measuring an enzyme called thiopurine methyl transferase from a blood test. For people with only low levels of this enzyme, there is a risk that the drug will build up and produce the harmful side effects mentioned above.
This medication comes as capsules and also works by suppressing the immune system. It is not commonly used in eczema treatment.
Ciclosporin lies somewhere between steroid and azathioprine in the way it is used and may be given for medium-term courses of a few months, which can produce a dramatic effect. Where treatment options are limited, ciclosporin may be used for longer than three months if it is effective and the side effects are well tolerated.
Ciclosporin tends to increase blood pressure and reduce the efficiency of the kidneys. Both the effects can be monitored, the latter by blood tests, and the dose altered if needed.
When used for years, it is possible that the kidneys in some people may suffer some long-term damage.
Like steroids, it may also make you vulnerable to infections.
A further side effect is that it can increase the amount of body hair both on the scalp and at other body sites. Although this is not a medical problem, some people find it distressing.
Blood cholesterol can also rise during long-term treatment. This can increase the risk of coronary heart disease and you may need to watch your diet and exercise more to counteract this effect.
Gamolenic acid (Epogam)
Gamolenic acid is an essential fatty acid found in evening primrose oil. It can be obtained from healthfood stores and similar outlets. Gamolenic acid is claimed to relieve some of the symptoms of eczema such as itching and inflammation but the evidence for this is inconclusive.
Light treatments for eczema
People often notice how eczema improves when they go on a sunny holiday. This is probably as a result of many factors acting together (see Stress), including the effect of sunshine.
Ultraviolet radiation (UVR) can suppress the activity of immune cells in the upper layers of the skin. For people with eczema and psoriasis, this is helpful and can calm down their rash. At the same time, UVR damages the skin, altering the genetic material, deoxyribonucleic acid (DNA), in the cells. Damaged DNA may produce abnormal cells that do not function properly. Some of these cells can develop into skin cancer if the damage is severe or if the UVR exposure is intense or prolonged.
Natural sunshine contains several different types of UVR in doses that are random and difficult to quantify. Medical light treatments are designed to overcome this variability and deliver well-controlled doses of UVR to the skin over a period of several weeks. The dose is gradually increased to avoid burning, which is both uncomfortable and damaging.
If eczema is severe, it is sometimes necessary to start a course of steroid tablets for the first few weeks of UV therapy, until the light treatment takes over and the tablets can be stopped. Towards the end of the course of light treatment, the eczema should settle so a smaller amount of steroid is needed. The UV therapy may then be stopped, or administered less and less often to ensure that the skin remains stable as therapy is withdrawn.
Types of light treatment
This is an old-fashioned form of light therapy. It is moderately effective for some people and has a good record of producing little long-term harm to the skin.
This is a newer form of UVB sometimes referred to as TL01. It was developed to obtain the benefits of a certain wavelength of light (311 nanometres) and is useful for some people. It is, however, more easy to burn with narrowband UVB than with the more old-fashioned form (broadband UVB).
UVA1 is available in only a small number of centres. There are limited studies to indicate that it might be helpful in eczema. It is a longer wavelength than the standard UVA used in combination with psoralen medicine in PUVA.
Pronounced ‘poovar’, this stands for psoralen UVA. Psoralen is a natural plant extract that increases the sensitivity of the skin to sunlight.
It was used by the Ancient Egyptians for another skin problem called vitiligo. They rubbed themselves with the broken leaves of plants rich in psoralens, then lay on the banks of the Nile to get their PUVA treatment.
You would take psoralen either as a tablet/capsule or by soaking in a bath full of dilute psoralen solution for 10 minutes, before standing in a light cabinet. The chemical makes you more sensitive to UVA than UVB, so the light cabinet is designed to give you this form of radiation.
PUVA is possibly more effective than other forms of UVR in eczema, although opinions differ. However, the tablets can cause nausea or light-headedness.
In the longer run, PUVA also appears to damage the skin, although most evidence has built up in patients with psoriasis. After 20 courses of PUVA (each one may last about six weeks), many people with psoriasis end up with visible damage to their skin that resembles sun damage.
Some of these people with psoriasis later develop skin cancer. There is less experience of this treatment in eczema, but the same problems would probably occur if the treatment was used without restriction.
What about solaria and home UV cabinets?
Some of these facilities may help the skin but dermatologists are concerned that the amount and types of UVR are not those best suited to treating eczema. Wavelengths that tan the skin may not be best for improving eczema.
In addition, you might be tempted to use home UV cabinets on a frequent basis and indefinitely. Although in the short term these cabinets are usually safe, they can produce sun damage and skin cancer if they become part of a frequent routine.
In contrast, PUVA is given in the hospital like radiotherapy, with careful records of the doses and regular checking of the equipment and your skin. When you have reached a number of doses that would be considered the upper limit of normal, an alternative treatment would be sought. The incentive to do this with home cabinets or solaria is not present until something goes wrong.
What about sunshine?
Sunshine helps improve many forms of eczema. However, it needs to be exploited carefully.
It is important that young children are protected from excess sunshine for fear of burning and increased risk of skin cancer in later life. Careful exposure to sunshine in gradually increasing amounts during a season or holiday usually helps to reduce eczema. Always use sunblock if there is a risk of sunburn and expose the body in moderation to avoid long-term skin damage.
There is a small group of people for whom sunshine is not helpful, either because their skin is too prone to sunburn, or because they have an unusual kind of eczema that can be made worse by sunshine. The latter are usually adults over the age of 50.
Light treatment in special groups
UV treatments are used in some children with severe eczema uncontrolled by other methods. However, these treatments should be kept to a minimum. A child’s skin is thinner than that of an adult and possibly more vulnerable to the long-term damaging effects of UVR.
Also, if we consider that for many types of UV treatment there is a maximum lifetime dose – for example, 20 courses of treatment – it is preferable not to receive it all early on. Once you have had your 20 courses of PUVA, for instance, then it is no longer available as a treatment option.
Sometimes this predicament has to be accepted with the hope that new treatments will be available when the lifetime dose of UV treatment has been reached, or that the character of the eczema will change with time.
Narrow and broadband UVB are probably safe in pregnancy, but it is hot in UV cabinets and this can cause fainting. This will rule it out in pregnancy if you are anaemic or your blood pressure is low. The use of a drug means that PUVA should not be used in pregnant woman.
People with very fair or sensitive skin
Some people are excessively sensitive to sunshine and any attempt to treat them with UVR may cause burning. This does not rule out UV treatments in these people, but may make it an unpopular choice. Another factor is that those who are likely to burn also suffer sun damage more readily and have a lower threshold for skin cancer. UVR is unlikely to be chosen for people whose eczema is made worse by sunshine.
Occlusion therapies involve covering the skin with special clothing, bandages or dressings to do the following:
• prevent scratching and contact with other irritants, allowing the skin to heal
• enhance absorption of treatments into the skin, most typically steroid cream or ointment.
Occlusion increases absorption of steroid severalfold. This is helpful in the short term, but care must be taken to avoid the risks of steroid side effects, which are increased if occlusion is used for prolonged periods with stronger steroids.
The guidelines concerning amounts of steroid to use do not apply when special occlusive dressings are used. These guidelines apply to steroid treatments used with no occlusion, where absorption is less.
The simplest occlusion is clothing and the value of this is most obvious in infants and children who will automatically scratch an area that itches, making the eczema worse as part of the ‘itch–scratch cycle’.
Certain materials, such as wool, tend to irritate skin with eczema, probably as a result of the small, protruding fibres. Synthetic garments may not allow evaporation of sweat so cotton is generally favoured for those with eczema. It combines lack of irritating fibres with the capacity to ‘breathe’. Silk may be an alternative.
Scratching is usually less during the day, so there can be greater flexibility with daytime clothing. Night-time, however, can be more of a problem and the following suggestions may help:
• Choose all-in-one suits with integral feet for children aged up to 30 months. Integral mittens are found with some garments.
• Choose two-part pyjamas or all-in-one suits for children over 30 months.
• Tie mittens on with cotton ties or sew onto pyjama arms – cut thumb holes in the mittens if needed.
• Use a cotton cap for children with severe scalp eczema. If the cap is pulled off, make a disposable head covering from part of a tubular bandage tied off at the top, and with a hole cut in the front of the tube for the face.
• Tubifast comes as a tubular bandage and also as clothing. These are thin cotton garments with the seams sewn on the outside. Tights, leggings, socks and vests can be prescribed for children between 6 months and 14 years. These are available on a normal prescription from your GP.
Think flexibly at all times. You may come up with a different way of dealing with a particular aspect of the problem and there are no fixed rules. However, it is important that whatever you use is safe and does not result in tight or twisted clothing around the neck or limbs.
Bandaging can be used in all age groups and is useful for many different types of eczema. It is most easily used on the limbs, although modified bandages can be used on the trunk, head and neck.
Bandages are usually applied over a layer of ointment or cream and may be left in place for several days or changed daily. For children at school, it is sometimes useful to use the bandages at night and take them off in the morning.
Alternatively, bandages may be used over the weekend. Adults often prefer to leave bandages on limbs for two to three days to save on the time taken for repeated dressings.
Some bandages can be re-used if washed but may gradually lose shape and elasticity. It is possible to buy nets for the washing machine. Put the bandages in the net to prevent these long items tying everything in a knot.
Bandaging a child
When bandaging a child or infant, it is important that you are well prepared and the circumstances are as good as possible. Some of the following suggestions may help:
• When doing it for the first time, prepare things carefully, lay the items out in sequence and don’t do it last thing at night as an act of desperation.
• Have another responsible person around to help.
• Plan something to divert your child at the same time, unless he or she can be fully involved with the bandaging itself.
• Avoid having young siblings around if they are likely to compete for your attention.
• Put a towel on the floor where you will apply the bandaging.
• Have a clear idea of what you are going to do.
It may be possible to practise on a doll, teddy or cooperative child of similar size.
When people with severe eczema are admitted to hospital they may be given a body suit to wear. This is a tailor-made garment made from Tubifast. Different sizes are chosen for the trunk, legs and arms.
A generous length of single or double thickness is applied to each limb and the trunk. The arms go through holes made in the top of the trunk bandage. In the armpit and groin, the limb lengths are joined to the trunk by ‘ties’ threaded through small holes in the edges. A gap is left in the groin, with the trunk bandage coming down over the bottom without being tied.
At the free edges of wrists, ankles and neck, the bandage can be rolled back a short way and, at wrists and ankles, can be held in place with a bracelet of sticky paper tape (Micropore). Alternatively, mittens or foot covers can be made with further Tubifast and attached to the rest of the suit with ties.
A body suit can be used over any treatment and people sometimes choose to wear one under their clothes at work. The benefits are weighed against the increased heat and sweating it may cause. A limited suit, such as on the arms, may be useful under a shirt.
If you are going to use a body suit regularly, keep a record of the right lengths for different parts of the body. The tubular bandage can be cut out more quickly at each dressing.
Mittens, gloves and boots
These can be made easily from Tubifast. Slip a length of Tubifast onto the hand/foot and a short way past the wrist/ankle.
Stretch the fingers/toes out and then cut the length to slightly more than twice that already on the limb. Then twist the Tubifast at the finger/toe tips before rolling it back over the hand and up the arm, to lie double over the first layer.
Use a Micropore bracelet around the top, preferably without applying the tape to the skin, which can cause irritation.
A head cover can be made with a piece of Tubifast, joined with ties at the neck to the trunk bandage and taped, tied, knotted or stitched at the top. Holes are cut for the eyes and mouth. Beware of using scissors while the head cover is on an infant or child.
A wet wrap is a way of applying a modified body suit over any part of the body below the head. Wet wraps are usually used in children.
Two layers of tubular bandage are applied over a thick layer of skin treatment. The first layer of bandage is wet and the second is dry. The added wetness of the first layer allows more evaporation to cool and soothe the eczema.
The bandages are available through your GP or can be purchased over the counter, although they are quite expensive. Usually bandages can be re-used a few times. The inner one will become stained with grease and need washing, but it does not need to be spotless.
Grease can harm the rubber seals on washing machines. A pre-soak in a bucket of detergent may keep this problem to a minimum. Make sure that all detergent is well rinsed out.
Which skin treatments can be used with wet wraps?
Any standard skin treatment can be used with wet wraps, particularly emollient or topical steroid. However, like all occlusive methods, there is a risk of absorbing excess steroid into the system if used long term.
For this reason, wet wraps in children use hydrocortisone or diluted steroids such as Propaderm 1:10 (diluted to 10 per cent in an ointment by the pharmacist). It is routine to use up to 500 grams of the diluted 10 per cent steroid mix for a couple of weeks before reducing to 250 grams per week.
It may be necessary to continue with this quantity in some children for many months, while the doctor keeps treatment and possible side effects under review. As the skin settles, it is useful to use emollient alone with wet wraps to protect the skin and prevent itch.
Applying the wraps
The bandages are applied in two layers and are the same as a body suit of Tubifast. The lengths are measured out before starting. It is better to make them too long rather than too short.
The first layer of bandage is soaked in tepid water, then wrung out so that it doesn’t drip but remains fairly wet when put on. The first layer is then covered by the second which is dry. The process starts with the trunk and is repeated for the arms and legs. The joins are tied and the free edges tied up or rolled.
Adhesive occlusive dressings
Adhesive dressings may be used over limited areas, provided that the sticky part of the dressing does not adhere to affected skin. Examples of such dressings include simple sticky plasters over splits in the hands and feet, and Granuflex, Duoderm or Tegaderm, which are flexible materials (hydrocolloids) that come in squares of various sizes to be cut as needed, like sticky-back plastic.
Hydrocolloid dressings are seldom used in childhood eczema, but can be useful for stubborn patches of well-defined eczema away from the face in adults. The absorption of steroid is massively increased by the use of hydrocolloid and prolonged use with a steroid ointment or cream is rarely warranted.
Hydrocolloids are moderately water resistant. They become spongy and soft after soaking, but dry out again and remain stuck down through infrequent and modest wettings. This means a dressing may be left in place for three to seven days depending on location.