Skin Care World

The views expressed below are those of the author, and are not necessarily those of Mölnlycke Health Care.

The views expressed below are those of the author, and are not necessarily those of Mölnlycke Health Care.

Sufferers tormented by the itch of eczema are desperate for anything to clear the unbearable desire to scratch, and long for their skin to regain its smoothness and softness.

However, some are frightened by stories of the skin thinning side effects of steroid creams. Others may prefer ‘natural’ treatments such as herbs, even though they may have little or no scientific evidence to support their efficacy or safety. They may even try mysterious and unusual alternative remedies. These choices are understandable, but the health practitioner working with patients with eczema may find it impossible in the limited time available to counter these attitudes. Nonetheless, an effective solution has to be found which is acceptable both to the patient and to the Healthcare Professional.

WHAT IS ECZEMA?

The skin in eczema is commonly short of oil. This shortage is made worse by the use of soap, shampoo and by exposure to detergents and results in dry, scaly, itchy skin. Scratching the skin can also lead to bleeding and infection. How can this be sorted? Moisturising the affected skin is usually a good start.

THE VALUE OF MOISTURISING

Moisturising creams (emollients) can be used as an alternative to soap for washing. Not all moisturisers are suitable for this but some products such as aqueous cream, emulsifying ointment and Epaderm ointment have been formulated so that they can mix well with water. In addition to being used as a substitute for soap, such products can be mixed with a little warm water in a jug and added to the bath water before bathing as a form of bath oil.

People with eczema often find that daily use of a moisturiser as a soap substitute for washing, then used throughout the morning and evening as a moisturiser, keeps the rash under control. As a result, they may only need to use a steroid ointment, or other eczema treatments such as tacrolimus and pimecrolimus, for a few days at a time to deal with the eczema when it flares up. In this way, the moisturiser often reduces the total quantity of steroid used.

MAKING THE RIGHT CHOICE

It is important, however, that such products have a minimum number of ingredients that may cause an allergic reaction. Many commonly prescribed bath oils and moisturisers contain perfume, preservatives or lanolin that are known to cause sensitivity rashes, especially in those already suffering from eczema.

Even the 50/50 mix of liquid paraffin and white soft paraffin, used by dermatologists very widely, does not suit everybody, not least because it makes clothes greasy.

Aqueous cream is very widely used as a soap substitute – but occasionally users with eczema complain that it stings and its preservatives occasionally cause allergies.

Emulsifying ointment is a more concentrated aqueous cream, which is both cheap, preservative free and effective, although some patients can find it too greasy.

Epaderm is a form of emulsifying ointment that many people find easier to use, so compliance with treatment may be better. It contains no fragrances, colourings or additives. Originally developed by the Royal Victoria Infirmary, Newcastle Upon Tyne, it is supplied in 125g and 500g tubs.

These emollients may all be bought over the counter and are also available on Drug Tariff and can be prescribed by nurses. There are many other moisturisers available and it is nearly always possible to find one which suits the individual.

WET WRAPPING WITH MOISTURISERS SUCH AS EPADERM

In children with eczema, moisturisers are usually an essential part of the treatment to clear the problem and to prevent recurrence. However, regular application of the moisturisers may be difficult due to resistance from the children and the time needed by parents busy with work, home and other commitments. Wet Wrap treatment is widely used for children with eczema, which may allow much larger quantities of moisturising creams to be used.

Wet Wrapping involves the application of a steroid cream first, if required, to the areas affected by eczema. A moisturiser, such as Epaderm, is then applied very generously. Two layers of Tubifast 2-Way Stretch bandages are then used: the bottom layer damp and the top layer dry. The wraps protect the child’s clothes from the grease of the moisturiser. They also provide a pleasant cooling sensation, which appears to reduce the itch for most children. They provide a physical barrier to break the vicious cycle of itch-scratch-infection, which keeps the eczema active, and distresses parents and children so much. (If the wraps dry out then the top layer can be peeled back and more cool water applied, which evaporates and cools the skin, so reducing the itch.)

Most parents find that it helpful to be shown how to do the wet wrap treatment by a paediatric dermatology nurse who can show them how much cream to use and how to wet and attach together the Tubifast 2-Way Stretch bandages. Some parents find that Tubifast Garments, clothing made out of Tubifast material, are more convenient and quicker to use than Tubifast 2-Way Stretch bandages for wet wrap treatment in children with extensive eczema.

Parents can be reassured that, although steroid creams or other active creams are almost always needed initially in proper quantities to control eczema, as time goes by most children will only need to use them intermittently. The eczema may sometimes then be controlled using Wet Wraps and moisturisers alone.

PROCEED WITH CAUTION

Despite their successes, Wet Wraps are not a panacea. Some children, for example, those with infected eczema, may be made worse by Wet Wraps. Their infection should be treated first. Some children hate having them applied and the benefits of an experienced, patient, and calm dermatology paediatric nurse with a sense of fun is invaluable. Also, some children with eczema do not improve with wrapping, and they may benefit instead from paste bandages (e.g. Steripaste or Ichthopaste). However, Wet Wrapping is often a very effective and safe short-term treatment for severe atopic eczema in children who have failed conventional treatment with steroid and emollient application.

CONTINUING SUCCESS

In the Norfolk and Norwich University Hospital dermatology department, doctors and nurses use a combination of these treatments, including Wet Wrapping with emollients. By selecting the most appropriate treatment for each patient, and working with a good humoured and supportive educational role, they are able to help parents understand the issues and separate the myths from the facts. In this way, parents and children are empowered to take control of the condition – a vital first step on the road to recovery.