AUTHOR: Dr John Ashworth
Dr John Ashworth is a leading Consultant Dermatologist and is registered with the General Medical Council of Great Britain and the Irish Medical Council. Educated at St.Bedes College in Manchester and Manchester Medical School, he carried out his medical elective at Johnston Willis Memorial Hospital in Virginia, USA.
At www.dermatologist.ie we offer online Consultant diagnosis/advice and prescriptions for patients
60 Second Summary
First, a point of clarification – many think the word “eczema” implies a genetic condition and “dermatitis” implies an external allergic problem – in fact, both terms to a dermatologist are interchangeable / mean precisely the same thing.
What does a dermatologist mean when they refer to “seborrheic dermatitis”? This refers classically to a rash predominantly on the face affecting the T zone where the production of the skins natural oil called “sebum” is at its maximum.
Sufferers of eczema will often recall a history of eczema as a young child which then faded away for many years before reappearing as eczema in adult life. The classic distribution of this condition is on the inner flexural aspects of the elbows and knees but is usually widely scattered elsewhere as well.
Allergy testing is a specialised field of dermatology which is hard to gain access to because this is only perform by a small number of dermatologists and correct patch testing involves up to 4 separate hospital visits therefore it is time consuming and expensive.
Try whenever possible not to use standard soap on the skin and instead use a moisturizing cream as a soap substitute and generally speaking have a good skincare programme to the affected area.
Do you understand the potential causes of eczema (genetic, allergic, infected) and the relative strengths of your skin treatment options? Have any skin exposure circumstances have changed? Does allergy need to be considered?
1. REFLECT – Before reading this module, consider the following: Will this clinical area be relevant to my practice?
2. IDENTIFY – If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area.
3. PLAN – If I have identified a knowledge gap – will this article satisfy those needs – or will more reading be required?
4. EVALUATE – Did this article meet my learning needs – and how has my practise changed as a result? Have I identified further learning needs?
5. WHAT NEXT – At this time you may like to record your learning for future use or assessment. Follow the 4 previous steps, log and record your findings.
Management of Common Skin Conditions
Provision of specialist services for dermatology is limited therefore many patients will seek High Street advice from their local pharmacy. The bulk of dermatological problems consist of the following four situations –
1. Skin cancer
2. Acne
3. Eczema / Dermatitis
4. Psoriasis
This article is concerned with items three and four
Eczema/Dermatitis
First, a point of clarification – many think the word “eczema” implies a genetic condition and “dermatitis” implies an external allergic problem – in fact, both terms to a dermatologist are interchangeable / mean precisely the same thing. Dermatologists would hardly ever use those terms without an explanatory prefix for example SEBORRHOEIC ECZEMA or ALLERGIC CONTACT DERMATITIS thus designating a subcategory which is important in terms of management / advice
The classic genetic variation is called ATOPIC DERMATITIS and is often linked to asthma, hayfever and these patients are generally “skin sensitive” – have irritations with simple products like moisturisers / sun screens / soap powders etc Many patients have overlaps of 2 types of eczema – so don’t get hung up on the “name” . Thus, many patients will have a genetic history of the atopic conditions but will also display a seborrheic pattern of skin trouble so they are in an overlap situation
SEBORRHOEIC DERMATITIS:
What does a dermatologist mean when they refer to “seborrheic dermatitis”? This refers classically to a rash predominantly on the face affecting the T zone where the production of the skins natural oil called “sebum” is at its maximum.
So the eyebrows, forehead and the naso labial folds are often the dominant area – other areas include the front of the chest, between the shoulders and sometimes the armpits and groins.
Some patients seem to be suffering an allergic reaction to a naturally occurring tiny organism which lives on human skin and this is why the application of KETOCONAZOLE can be helpful. Either in the form of a shampoo which can be scrubbed onto the skin when wet in the shower or applied in the normal way as a cream. For similar reasons DAKTACORT cream or DAKTARIN or other anti-fungal / anti-yeast creams are the mainstay of treatment.
This theory is also the explanation as to why this condition recurs – because you can only kill this organism off for a period of time before it naturally repopulates the skin once again
ATOPIC DERMATITIS/ECZEMA:
This is the classic form of the disease which is strongly genetic in origin and therefore there is often a personal or family history of the other “atopic” conditions which are asthma and hayfever.
Sufferers will often recall a history of eczema as a young child which then faded away for many years before reappearing as eczema in adult life. The classic distribution of this condition is on the inner flexural aspects of the elbows and knees but is usually widely scattered elsewhere as well.
A very important aspect of this condition is OIL DEFICIENCY in the outer layer of the skin and therefore greasy ointments applied very regularly are a hugely important part of treatment – in fact I often say this to patients – if you were to live on a desert island with only one product that you could use for the rest of your life – it would not be a medicated steroid – it would be a greasy ointment like simple VASELINE or even natural OLIVE OIL – because long-term this would give you best benefit.
Another important consideration is this – skin infection can spread rapidly in patients with eczema and the commonest cause of badly flaring eczema is infection – oral antibiotics such as FLUCLOXACILLIN may need to be instituted from time to time and is usually taken for 14 days at a dose of 500 mg 4 times per day
ALLERGY – if the nature of the condition radically alters over a fairly short space of time, and if infection seems unlikely, then consider the possibility of an allergy to something in the environment and that would also include prescription creams as a possibility – patients with geneticbased eczema are more prone to allergy – allergy patch tests are sometimes needed.
The commonest allergies relate to cosmetic creams, but also prescription creams – plant pollen in the environment – cookery products contaminating the skin – nickel in jewellery and possibly in the diet but there are many other possible allergens.
Allergy testing is a specialised field of dermatology which is hard to gain access to because this is only perform by a small number of dermatologists and correct patch testing involves up to 4 separate hospital visits therefore it is time consuming and expensive.
STEROID CREAMS – these are important but should be reasonably minimised for two reasons – firstly damage to the skin – secondly resistance – because in a similar manner to over treating patients with antibiotics and developing antibiotic resistance – something similar can happen with regular use of steroids therefore a rotation policy using several different products it’s tremendously important in the long run.
My own personal strategy for many patients would include the following 10 day reducing program of topical steroids.
For a temporary period of 10 days I would like to consider the following – only the third is suitable for longer term use the first two should be used exactly as directed – all applied twice per day – once the cycle is complete you should break from all prescription treatments for at least three days and use a moisturiser/skin care programme only.
If needed you can then recommence the cycle after this total period.
The treatment cycle can be shortened of course if you improve very rapidly which is possible but the critical arithmetic is to be completely away from active prescription creams for a three-day period before recommencing your cycle once again.
So the 10 day treatment is as follows:
BETNOVATE: twice per day for 2 days, then;
EUMOVATE: twice per day for 3 days, then;
DAKTACORT: twice per day for 5 days to follow
This adds up to 10 days
Having emphasised these issues about Steroids it is also important to counterbalance this with the fact that some patients and also health professionals carry a steroid phobia. By this I mean they are reluctant to apply steroids even in reasonable quantities and for reasonable time periods and are thus denying adequate treatment when active treatment is required.
Try whenever possible not to use standard soap on the skin and instead use a moisturizing cream as a soap substitute and generally speaking have a good skincare programme to the affected area.
TACROLIMUS and associated medications are useful in some patience and have a different action to Steroids. These treatments can irritate the skin in about 30% of patients and thus can be problematic. But certainly useful as an alternative to consider.
SUMMARY
Do you understand the potential causes of eczema (genetic, allergic, infected) and the relative strengths of your skin treatment options? Have any skin exposure circumstances have changed? Does allergy need to be considered?
TOP TIP 1: Most flaring eczema is NOT due to environmental changes – flaring eczema is usually due to normal skin bacteria being scratched into the skin surface and multiplying – thus, INFECTION is the commonest cause of flaring eczema. So adding an antiseptic topically or an antibiotic orally (FLUCLOXACILLIN 500 mg x4 per day for 14 days) will often make a dramatic difference.
NEWLY DEVELOPED ECZEMA: if the problem is recent – then consider circumstances – external allergy may be of relevance – starting work as a hairdresser, nurse, food industry – any wet work / regular hand washing is a potential problem – these considerations are important.
Wet work – both domestic and occupational, can obliterated the adhesion between the top of the fingernail and the nailfold skin thus allowing contaminants underneath the skin and this can precipitate nasty finger and hand eczema – hand protection by using cotton gloves inside rubber gloves when doing any dirty or wet work can be tremendously helpful.
In sunnier months eczema can flare and many patients can be sensitive both to direct sunshine but also to airborne pollen landing on the skin – FINGER TO FACE transfer of allergens (eg in the garden; cookery products; nail varnish) is another very important cause of face and neck eczema.
In colder months eczema can also flare for different reasons –the skin tends to be less oily in winter and needs more emollient and protection from prolonged exposure to cold and wind.
TOP TIP 2: Empower yourself with further information eg www.dermatologist.ie ; www.dermnetnz.org ; www.BAD.org.uk Give your creams a star rating with your dispensed steroids so you can understand the different strengths of steroid creams eg BETNOVATE ++++ ; EUMOVATE ++; HYDROCORTISONE + ; EMOLLIENTS zero pluses – and appropriate / inappropriate body locations for the different strengths.
When I see patients on multiple steroid creams I often ask them to put the creams on my desk in strength order from top to bottom and often they have very little idea about the relative strengths.
DAKTACORT is a good +1 product for most facial eruptions and covers both SEBORRHOEIC and also ATOPIC disease.
All forms of eczema have a common abnormality, OIL DEFICIENCY in the skin (not water deficiency) – therefore the term “dry skin” is very misleading. Oily greasy products like VASELINE work well but you cannot go out wearing them more cosmetically acceptable moisturisers are often preferred. The preference is purely personal – there is no “best” product.
CLINGFILM – if you apply a treatment to the skin and then wrap the kitchen clingfilm temporarily over the area this enhances the penetration and effectiveness of the cream or moisturiser. This is a particularly useful technique to use overnight in bed – and can make a very dramatic difference to a number of patients.
KEY QUESTIONS:
Past personal and family history of eczema / asthma / hay fever – indicates a genetic disease
Recent sudden onset with no past history indicates the possibility of external factors
A scaly dandruff like appearance on the face, scalp or upper body indicate a likely SEBORRHOEIC DERMATITIS type problem
Sudden deterioration of a previously lower level problem indicates likely infection or allergy
OVERALL STRATEGY:
Try to establish a likely diagnosis by appropriate consideration of family genetics
Think about external causation if possible
Tackle infection if present
Use plenty of oil replacementMake sure you have a grip of steroid potency in the products you use
PSORIASIS
Usually has a different appearance to eczema and the main characteristic differences for standard psoriasis are the fact that individual patches come to an abrupt end and quickly switch to normal skin rather than gradually fading towards normal skin which is more typical for eczema. Also, Psoriasis tends to be drier and thicker as a condition.
These distinctions are not universal and quite commonly it is difficult to differentiate between the two conditions even for experts.
DIFFERENT PATTERNS: There is a very strong genetic tendency. There are a few different patterns of Psoriasis but the classic shows the thick plaques. Other forms can affect just the flexures only, for example the armpits and the perineum. Other patients find that the scalp is predominantly involved. Other much rarer patients find their joints become arthritic before the appearance of the rash which can take many years to manifest. In other words Psoriasis is a complex disorder of the immune system which can affect the joints as well as the skin.
BIOLOGIC THERAPY: Over the past decade the pharmaceutical industry have developed treatments broadly referred to as the “biologics”. These consist of chemicals which either bind to specific antibody sites in the immune system or interfere with the immune system cascade of chemicals many of which are called “interleukins”. Inter meaning “acting between” and leukins referring to the leukocytes – the white cells of the immune system.
However, these medications are very complicated, very expensive and tend only to be used for extreme sufferers. The majority of psoriasis sufferers have a milder disease which can usually be adequately controlled with safe external cream treatments applied in the normal way.
ROTATION POLICY: Treatment on the skin for psoriasis is usually best achieved using a rotation policy – approximately one month on each product in a triangular rotation so that the psoriasis is attacked in different ways by different molecules and this seems to be the best way to control it – below I will give you a prescription for three products that would be a good rotation policy to consider
All treatments need to be applied and left on the skin for at least 30 minutes on each treatment session to allow good penetration into the skin and maximum benefit
The three reasonable products I often recommend are as follows:
DOVOBET
EXOREX
PSORIDERM
Sometimes, if Psoriasis is very angry and inflammatory it is reasonable to apply a very strong steroid approach for example DERMOVATE for a temporary period of 2–4 weeks but strong steroids are not generally recommended for long-term use.
When treating psoriasis of the hairy scalp it is often difficult to get treatment into the base of the condition because of a thick surface protective scale which needs removing first. Greasy applications like COCOIS are massaged into the skin by parting the hair to expose the skin, applying the treatment then parting the hair fractionally further across the scalp and working across the entire area in this way. Then leave the treatment in position under a protective plastic shower cap for several hours, often overnight in bed – then shower out and massage with standard shampoo which will help shed a lot of the scale.
ENSTILAR and DIPROSALIC scalp liquid (as examples) are then able to be massaged in a similar way but can now penetrate into the root of the problem.
If it is not possible to control psoriasis by external treatment then oral medications can be considered and these include the following – METHOTREXATE, CYCLOSPORIN, MYCOPHENALATE and others. Usually GPs are reluctant to initiate these treatments without supervision by specialist and repeat blood tests are needed to ensure safety.
EMOLLIENTS: these are important in Psoriasis not so much as an oil replacement therapy as in the case of eczema – but more in the sense that the dry scaly surface thickening of typical psoriasis prevents the penetration of active treatment. Once the surface scale is softened and removed then active treatments can be more effective. Emollients also make Psoriasis feel more comfortable for the patient.
ULTRAVIOLET LIGHT: natural sunshine, sunshine of an artificial kind for example in a tanning parlour can sometimes be helpful but of course we all know these are harmful for human skin. So any recommendation to try these has to be counterbalanced by the harmful consideration and advice. Medical ultraviolet light refers to a very specific narrow wavelength of light which is particularly helpful for skin disease and much less harmful to the skin in general. However, this kind of light exposure is a specialised option which is mainly delivered from dermatology departments are therefore can be more difficult to gain access. Many patients report great improvement on a sunny holiday.
Q/A section:
ATOPIC DERMATITIS is characteristically associated with a greasy skin T/F?
False – it is usually associated with an oil deficient skin and emollients are a vital part of treatment
ATOPIC DERMATITIS is linked with other disease specific associations T/F?
Correct – very often there is a personal or a family history of associated asthma and hayfever – there is a strong genetic link
PSORIASIS has no other manifestations outside of the skin appearance T/F?
False – psoriasis sometimes is associated with certain types of arthritis and the arthritis can sometimes preceed the psoriasis by many years
PSORIASIS can appear at any age but is usually present from early childhood T/F?
False – psoriasis very rarely presents in childhood, unlike atopic dermatitis which is characteristically common in childhood. Psoriasis appears much more commonly in adult life and sometimes is associated with a severe sore throat as a trigger factor
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