The aims of eczema treatment are to soothe and control the condition. This will in turn reduce the irritation and soreness that can cause so much discomfort and disturbance in daily life. For most sufferers, there is no cure that clears eczema permanently, but it is important to keep a positive attitude about treatment as there is now more choice than ever before, and most people with eczema will be able to manage their skin with relatively simple and safe therapy.
A topical treatment is something that is applied to the surface of the skin rather than taken internally. The two most commonly used topical treatments for eczema are emollients or moisturizers and steroids.
Most eczema sufferers will be able to keep their eczema under control by using these treatments correctly. Other topical treatments for eczema include antibiotics to treat non-steroidal infections and the newer immunosuppressants.
Emollients and moisturizers
The term 'emollient' literally means a soothing, calming substance. This name refers to simple moisturizers for use on eczema and other skin complaints, rather than cosmetic moisturizers which contain many more ingredients and additives. Most people use the terms 'emollient' and 'moisturizer' interchangeably, but strictly speaking an emollient simply acts as a barrier to prevent loss of the skin's own moisture while a moisturizer has additional humectants substances that increase the water content of the skin.
How do I choose the right one?
The wide range of emollients can be rather bewildering for any newcomers with eczema. The right emollient is the one that you like, so choose small pots or tubes first and see which you prefer. You may need several different emollients, for example, a lighter cream to use during the day at school or work, and a heavier ointment after bathing and last thing at night. Emollients can be bought without prescription but it is usually less expensive in the long run to have them on a National Health Service (NHS) prescription. It is important that you are prescribed sufficient quantities. For instance, to treat widespread dry eczema, a child will require 250 g/week and an adult 500 g/week.
As a general rule, the runnier the moisturizer, the less effective it will be. Greasy preparations that stay in the pot when tipped upside down are best for dry skin. Cosmetic moisturizers are not recommended because they are not intended for use on skin complaints, and may contain irritating or allergy-provoking ingredients such as fragrances. They are usually much more expensive than simple emollients and are not available on prescription.
Creams, Ointments, Lotions, Bath Oils, and Emollients
Moisturizers are recommended for all types of eczema because they promote rehydration of dry, cracked areas. Such products include Aquaphor, Eucerin, Moisturel, mineral oil and baby oil. It is recommended that the selected moisturizer be applied liberally to the affected area. Products containing alcohol may result in burning of the affected area, so it is best to choose the product with the smallest amount of alcohol. If you need assistance choosing a product, talk to your doctor or pharmacist.
Some emollients contain added ingredients to improve their effectiveness or to give additional actions:
The steroids used in the treatment of eczema and other inflammatory skin diseases are a group of substances called 'corticosteroids', which are related to the body's natural hormone cortisol. They should not be confused with anabolic steroids such as testosterone, which are used illegally by some athletes to build up muscles. Cortisol and other corticosteroids have many anti-inflammatory actions, which is why they are used for a variety of medical problems from asthma to arthritis. These anti-inflammatory actions include reducing skin blood flow and suppressing the influx of fighter white blood cells into the skin. They also slow the rate of growth of epidermal skin cells and dermal collagen fibres.
For most medical problems, steroids need to be taken internally, but one of the good things about treating skin complaints is that medications can work effectively when applied externally, i.e topically. There are fewer problems from using steroids topically than when they are taken internally. In the early years of use, before doctors ware aware of the side effects, strong steroids were prescribed for long-term treatment of skin complaints on delicate skin areas such as the eyelids, face and skin folds. This led to skin damage in the form of thinning (steroid atrophy), stretch marks (striae), 'broken veins' and persistent facial redness. However, it is now over 50 years since topical steroids were first used, and there is a great deal of experience in getting the best out of steroid treatment while minimizing the chances of skin damage. Unfortunately, the memory of steroid atrophy has lingered and it has created a phobia of steroids among eczema sufferers and their carers. Sometimes this anxiety leads to the eczema sufferer being denied safe effective treatment and relief of symptoms.
Topical steroids are usually very effective at suppressing mild to moderate eczema as well as other inflammatory rashes. This gives the skin a chance to heal and helps break the itch-scratch cycle that worsens eczema. However, it would be a mistake to think of steroids as a cure and eczema may come back or relapse when the treatment is stopped. This can cause frustration for eczema sufferers because it makes treatment seem like a game of snakes and ladders.
Although topical steroids look similar, there is a world of difference between the effectiveness and safety of strong or very strong steroids and mild steroids. In general, the stronger the steroid, the more effective it is, and the more likely it is to cause unwanted effects such as skin atrophy. For this reason, only mild steroids should be used on delicate areas such as the eyelids. However, these are usually ineffective on the thick skin of the palms and soles, where a stronger steroid is needed. The choice of steroid also depends on how severe and widespread the eczema is. Small stubborn patches of very active eczema such as lichen simplex may need a strong steroid, but a milder i steroid would be used to treat a larger body area. Young children (under five years) are usually prescribed mild steroids, although occasionally they may need stronger preparations.
Like moisturizers, topical steroids come as ointments, creams and lotions that vary in their greasiness. There are also gels for hairy areas like the scalp. In general, an ointment is best for dry, scaly, cracked eczema while a cream is easier to apply to weepy acute eczema. Ointments are more moisturizing and contain fewer additives such as preservatives.
Some steroids contain additional active ingredients, including the following:
One of the problems with tubes of steroids is that they do not have any coding to indicate their strength. It is very important that people applying topical steroids know exactly which ones to use on different body sites. If you are unsure, ask your doctor to write a simple list of what to use where, and mark the strengths on the tube packets, or speak to your pharmacist.
What to do if a steroid doesn't help
If a topical steroid does not seem to be working in eczema there are several possible reasons, including the following:
On rare instances, steroids can actually cause allergic reactions. This is easily overlooked because they also have anti-inflammatory actions. However, it should be suspected if someone's eczema gets worse after applying a topical steroid. If there is any question of allergy to any topical medicament including steroids, patch tests should be carried out.
The skin surface in eczema has tiny cracks, which can make it prone to infections. This is especially true of atopic eczema, but also applies to other forms of eczema such as discoid eczema, hand and foot eczema and contact eczema. For this reason, topical antibacterial or antifungal agents (antibiotics) are sometimes combined with a topical steroid. Combined preparations are especially useful at certain body sites, such as the anogenital area or the feet, where a variety of microbes can cause infections.
However, long-term use of topical antibiotics is not recommended as it encourages growth of resistant bacteria. People can also become allergic to topical antibiotics, which means that using them will actually make the eczema worse.
One of the latest developments in eczema treatment is a new group of drugs called 'nonsteroidal immunosuppressants' or 'topical calcineurin inhibitors' (TCls). When taken internally, these drugs have a powerful dampingdown or suppressant effect on the immune system, which is why they are used to prevent the rejection of transplanted organs. When applied to the skin, non-steroidal immunosuppressants reduce the over activity of the skin's immune system that occurs in eczema. At present the two drugs of this kind which have been approved in the UK for treatment of atopic eczema are:
Topical tacrolimus has been found to be as effective as a potent steroid, and is more effective than pimecrolimus cream.
The major advantage of using topical nonsteroidal immunosuppressants is that, unlike topical steroids, they do not cause skin thinning (atrophy). This could be especially useful when treating eczema on thin areas of skin such as the eyelids, face and neck.
Studies have shown that very little medication gets absorbed into the body, so these drugs appear safe from the point of view of internal side-effects. However, there are theoretical concerns about their long-term safety, in particular whether they will increase the chances of skin cancer because of their suppressant actions on the skin's immune system. Skin cancer is already an increasingly common problem in fair skinned-people. It does not usually develop until later in life, and therefore it could take many years before a cancer-promoting effect of a new treatment becomes apparent. For this reason, pimecrolimus and tacrolimus are being used with caution at present, and are not recommended as first-line eczema treatment or for children under the age of two years.
Topical non-steroidal immunosuppressants can cause an unpleasant burning and stinging sensation shortly after being applied to eczema. This generally settles with continued use as the skin improves.
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