Eczema

What is eczema and what causes it?

Eczema is a condition that causes the skin to be itchy, dry and red. It can flare up and down but can also be there all the time. It can be present from birth or occur later in life. Eczema can run in families and be linked to asthma and hayfever. This is called ‘atopic eczema.’ Skin irritants and/or food allergies can also contribute to eczema.

How is eczema treated?

Eczema affects the skin barrier letting water out and dust, irritants and bacteria in. Using a moisturiser (emollient) helps repair the skin barrier and protects it. Topical steroid creams reduce inflammation in the skin and reduce the appearance of redness.

Moisturisers (Emollients)

There are lots of different types of moisturisers including creams, gels and ointments. Often patients use a combination of these. Ointments are usually preferred by Dermatologists because they are better absorbed, last longer on the skin and contain fewer preservatives which can cause stinging and irritation

How do emollients work?

Emollients provide a greasy coating on the outer layer of the skin which improves the skin barrier and level of moisture within the skin. A variety of different types of emollient may be used throughout the day depending on how dry your skin is and whether you are going to school/work etc. For example, a cream may be preferred during the day but an ointment at night.

The vast majority of emollients can be used as a soap substitute as well (except white soft paraffin). Regular soaps, shower gels and bath foams can be very drying to the skin and cause irritation.

How much emollient is enough?

Emollients should be applied regularly to all the affected areas and can be applied multiple times during the day if required. If treating the whole body approximately 600g per week for an adult and 250-500g per week for a child.

Top tips for emollients

1. As a moisturiser

Smooth onto the skin immediately after bathing and apply as often as needed to prevent the skin becoming dry.

Ideally it should be applied 2-4 times per day.

2. As a cleanser

Apply liberally to the skin and wipe off with single layer of paper tissue, taking care not to damage fragile skin.

3. As a soap substitute

Mix emollient with water in palm to form lather. Apply to the skin in a downwards direction. Gently rinse lather off skin leaving a thin layer of the ointment on the skin. Pat dry.

4. In the bath

Ointments can be dissolved in water. Add a spoon full of ointment to a small amount of warm water in a jug to dissolve it then add to the bath water. Take care when getting out of the bath, as it may be slippy.

How should emollients be applied?

Step 1

Always wash your hands for 20 seconds before applying an emollient.  

Step 2

Do not put your fingers into the tub as this can introduce bacteria and cause infection. Use a clean spoon or a spatula to take your emollient out of the tub.   If your emollient is in a pump this can be done straight on to your clean hands.

Step 3

Apply to the skin in a downwards motion following the hair growth.   Do not rub in as this can block the follicles and cause infection.

What are topical corticosteroids?

Topical corticosteroids are anti-inflammatory preparations applied directly to the skin. They help reduce inflammation, redness and irritation.  They come in many forms including ointments, creams, lotions and tapes.  Ointments are generally used for dry skin conditions however if the skin is wet and weepy a cream is usually preferred.

What are the different strengths of topical steroids?

Your doctor or specialist nurse will identify the correct strength of steroid for you to use on different parts of the body. They will also discuss how to increase or decrease treatment appropriately using the steroid ladder.

Steroids

Severity of eczema 1 (mild) – 4 (very potent)

1. Hydrocortisone 1% (mild)
2. Betonate RD (Betamethasone 0.0.25%) and Eumovate (Clobetasone 0.05%) (Moderate)
3. Betnovate (Betamethasone 0.1%) (potent)
4. Dermovate (clobetasol proprionate) (very potent)

Calcineurin inhibitors

Severity of eczema (1 mild – 3 potent)

1. Primecrolimus (mild)
2. Tacrolimus 0.03% (moderate)
3. Tacrolimus 0.1% (potent)

How long should I use topical corticosteroids?

It is important that you follow the treatment plan given by your doctor or specialist nurse in order for your skin to avoid a flare of your skin condition. If used correctly topical corticosteroids should not cause side effects.  Thinning of the skin and stretch marks will occur only if a strong steroid is used incorrectly or over a prolonged time.

How should topical corticosteroids be applied?

Step 1

Always wash your hands for 20 seconds before applying a topical corticosteroid.  

Step 2

Squeeze the topical steroid in a line from the last finger crease to the fingertip. This is a fingertip unit (FTU).   One FTU would be sufficient to treat an area equivalent to two adult handprints.

Step 3

Apply to the affected area in a downwards motion following the hair growth.   Do not rub in as this can block the follicles and cause infection.

Step 4

Always wash your hands for 20 seconds after applying a topical corticosteroid.    

How much topical corticosteroid should be applied?

The fingertip unit method (FTU) gives a general estimate of how much should be used. One FTU would be sufficient to treat an area equivalent to two adult handprints. In children the fingertip and two handprints are based on that of an adult also. The tables below show how much is estimated to be used. This is based on the whole area being treated therefore if only a proportion of the area is affected the number of FTU should be adjusted accordingly.

Adults and young people

Children

Precautions

• Topical corticosteroids and emollients can contain paraffin which is flammable. Do not smoke, use naked flames (e.g. candles, BBQs, be near people who are smoking or using naked flames) or be near anything else which may cause a fire whilst these products are in contact with your skin, clothes dressings or bandaged.

• If a topical corticosteroid causes irritation, please seek advice from your medical or nursing team.

• If you are using an emollient as part of your treatment plan also do not apply these at the same time as it may dilute your treatment and cause it not to work effectively. An emollient should be applied 30 minutes prior to applying a steroid or vice versa.

• If you are having ultraviolet light treatment or radiotherapy, check with your medical and nursing team if there is any specific guidance on your emollient use prior to starting treatment.

• Topical corticosteroids do not contain SPF and should not be used as sun protection. They should not be applied prior to sun exposure. Sun creams should be used when skin is exposed to direct sunlight with a medium/high UV level.

• Topical corticosteroids can worsen skin infections. If you have a bacterial, viral or fungal skin infection they should therefore be avoided, unless they are applied with an anti-infective agent or you are started on tablet medication to treat the infection. 

Environmental Triggers

Skin conditions can be triggered by many environmental irritants which include house dust mite, pets, pollen, moulds, central heating, laundry and cleaning products. It is impossible to eliminate all triggers but you can minimise these with some simple measures.

How to reduce house dust mites?

House dust mites are one of the biggest triggers in eczema and other skin conditions. They are tiny insects that feed skin we shed and are found in soft furnishings.

• You can reduce the amount of dust mites in your home by: vacuuming carpets regularly- daily if possible.
• Vacuum mattresses, pillows and covers at least twice a week. Damp dust surfaces and floors on a regular basis.
• Avoid dry dusting, as this can spread dust into the air.
• Wash bed linen weekly on high temperature and wash curtains every 2-3 months.
• Limit soft toys, have one special soft toy in the bed and wash this regularly on a high temperature or put in a plastic bag and put in the freezer overnight to kill off the dust mites.

How to reduce irritation by pets?

It’s not pet fur that causes an allergic reaction. Instead, its flakes of their dead skin, saliva and dried urine. It may not be possible to remove a pet permanently but you could try:

• Keeping pets outside the house as much as possible.
• Not allowing pets into bedrooms.
• Washing pets regularly.
• Opening windows to increase ventilation.

How to reduce the impact of pollen?

Pollen allergyies / hay fever is triggered when trees and grasses release pollen into the air. Typically, people are affected during spring (trees) and summer (grasses).

To help keep this under control you could:

• Avoid drying clothes outside when pollen count is high.
• Keep doors and windows shut where possible.
• Shower and change clothes after being outside.
• Avoid grassy areas, such as parks and fields, particularly in the early morning, evening or night, when the pollen count is highest.

How to reduce mould?

Tiny particles released by moulds can also cause an allergic reaction in some people.  You can prevent this by:

• Dealing with any damp and condensation in your home.
• Keeping your home dry and well ventilated.
• Not storing clothes in damp cupboards.
• Removing any indoor pot plants from your home.

How to reduce the impact of central heating?

Central heating reduces humidity and dries the skin, making it itchy. You could control this by: Keeping your house at a comfortable 18°c. Hydrate your skin by applying moisturisers or emollient often when in the house

How to reduce the impact of laundry and cleaning products?

People with eczema should take special care with the items that come into direct contact with their skin. Fragrances (perfumes) and detergents can skin reactions. Air fresheners, candles, wax melts and diffusers are also irritants and use should be avoided.

To help keep this under control you could: Use non-bio washing powder when washing clothes. Use your washing machine’s second or “extra rinse” setting if it has one. Do not use fabric conditioner.

Useful sources of information

National eczema society

www.eczema.org

British Association of Dermatologists (BAD)

www.bad.org.uk

DermNet NZ

www.dermnetnz.org

NHS Choices (Atopic eczema)

www.nhs.uk/Conditions/Atopic-eczema

For Further Information

Medicines Information Patient Helpline:

Tel: 0191 282 3016. Available 9am to 4pm, Monday to Friday (excluding Bank Holidays). This helpline is available for patients of the Newcastle upon Tyne Hospitals, to answer any questions they may have regarding their medicines.

Dermatology:

Tel: 0191 282 0098. Available 9am to 4pm, Monday to Friday (excluding Bank Holidays).

Out-of-hours Advice:

Contact NHS 111 or visit your nearest NHS Walk-in Centre.

PALS:

If you have any concerns during your treatment please discuss this with the Dermatology team.

The Patient Advice and Liaison Service (PALS) can offer on-the-spot advice and information about the NHS. You can contact them on Freephone 0800 032 02 02 or e-mail northoftynepals@nhct.nhs.uk