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Diversity in skincare: RCN dermatology conference

Itchy and hard to hide, eczema and acne can make many children's lives a misery. Although neither has a cure, careful management and support can help to keep them under control. Nursing in Practice news reporter Nadine Woogara explains …

Nadine Woogara
BSc(Hons) PgDip
Nursing in Practice

Atopic eczema is one of the most common childhood ailments and acne the most common disease. Three quarters of children grow out of eczema while acne can persist long into adulthood, making their treatments unique. But the Royal College of Nursing conference on diversity in skincare on 28 November 2007, pointed out that three key points apply to successfully managing any dermatological condition:

  •       Proper skin treatment.
  •       Trigger reduction.
  •       Support and education for the family.

Managing childhood eczema
While healthy skin acts as a brick wall and a barrier to all irritants, dermatology specialist nurse for Conwy and Denbighshire NHS Trust Angela Steen, likened eczema skin to a brick wall littered with holes. The skin's production of lipids is impaired and its cells are dry and shrunken, allowing allergens to work their way in and provoke an immune response.

Many treatments have been developed over the years, but bath emollients for atopic eczema have been most recently in the public eye. Trusted for years, a poor write-up in the Drug and Therapeutics Bulletin in October 2007 caused uproar.1 But more recently, the National Institute for Health and Clinical Excellence (NICE) has spoken out and published its own set of guidelines for the use of nonperfumed emollients. NICE recommends that nurses should offer children with atopic eczema a choice of emollients to use every day for moisturising, washing and bathing. Angela Steen agreed, saying that patient choice should always be taken into account, as the best emollient is the one that the patient actually likes and will use again and again. She suggested that nurses should give out samples allowing patients to obtain a larger prescription from the GP once they have chosen their favourite.
Not only is it essential to choose the correct treatment it is also key to educate the child's family about emollient application. "Nurses have a pivotal role to play for both parent and child," said Angela. "They should advise on the top treatments, choice of emollients and have time to listen to their patients to discover what impact eczema has on their quality of life."
Itchy and scratchy
Of the two sides of eczema that require treatment, when it comes to children - the "itch" rather than the inflammation is hardest to deal with. Inflammation can be treated with topical steroids and immunomodulators, but children cannot simply be told to stop scratching. Angela Steen said that it's essential to break the "itch/scratch/itch" cycle, and recommended wet wraps either as tubular bandages, vests or leggings. These prevent the evaporation of water and rehydrate and cool skin while helping to prevent scratching from becoming a habit.
But itching can not only cause skin flare-ups, it can affect a whole family. Children with itchy skin can become irritable, find it hard to focus at school and sleep at night. Angela said that when thinking about eczema, nurses should treat the whole child and their family, not just their ailment.

Childhood acne
There are a number of myths surrounding acne. Some say spots are caused by poor diet and hygiene. Some say they're contagious, and most people think that acne is a childhood disease that people grow out of. Alison Bowser, Chief Executive of The Acne Support Group, was quick to lay these myths bare.
Acne is in fact most common between the ages of 15 and 19 years, she said, but it can persist into adulthood. It has four main causes. First, sensitivity to testosterone followed by abnormal cell growth, bacteria and sebum stimulated by a flush of hormones.
There are two main forms of acne, inflamed and noninflamed. Inflamed acne is characterised by papules, pustules and greasy skin. This can be treated with oral antibiotics, but if it results in a bout of side-effects, then topical antibiotics can be prescribed instead. It is important, says Alison, that antibiotic side-effects should be discussed. Many people have an irrational fear of antibiotics and do not want to use them, but this can be quelled through proper education.
Noninflamed acne is less severe and features black and whiteheads. Alison recommended benzyl peroxide and retinoids to loosen blocked pores and azelaic acid for darker skin types.
Whatever the type of acne, there are a couple of pointers to follow to get the best out of any treatment. Alison pointed out that television advertising often misleads its audience by suggesting that acne products can work overnight to produce beautiful blemish-free skin the next day. But this, she says, is approaching the problem from the wrong angle. Skincare management is not about emergency treatment, but preventing new spots from forming. She listed the following pointers for acne treatment:

  •       Ensure the treatment is applied to all affected areas.
  •       Give each product a minimum test time of two months.
  •       Consider where the acne is. Ask if it is on the back in a hard to reach area and then advise appropriately.
  •       Apply only the minimum amount of cream, using the fingertip for guidance.

Take into account lifestyle considerations. It's not easy for an active child to take one tablet four times a day. Treatments should be realistic and fit into the child's lifestyle, or they will not be adhered to.

Have you done anything about your spots?
Acne is a sensitive issue. So much so, that most patients prefer them to be described as "spots". Asking a patient about their family history of diabetes is not quite the same as asking if they have considered treatment for their spots. But Alison Bowser suggested that nurses should have more confidence to raise the subject first, without prompting. If you saw athlete's foot, she says, you would say something. So why not say something about spots? A study has found that half of patients said they were grateful and 12% said they were relieved when their healthcare professional brought up the issue of acne themselves. Nurses should be confident to quash the stigma that surrounds acne and raise the issue proactively.

Dermatological conditions do not enjoy the same recognition shared by mental health and cancer in nursing, but the RCN conference demonstrated that their influence over patients' lives should not be underestimated. The RCN dermatology conference audience welcomed these important insights into skincare and it seems that nurses throughout the profession are eager to raise the profile of dermatology.

1. Questions over eczema treatment. 3 October 2007. Available from

Your comments: (Terms and conditions apply)
"I have eczema, which is particularly troublesome on my face. I did have it as a child but it recurred when I was in my early forties.  When it flares up it makes me feel low, self-conscious and unattractive. I imagine it must be so much worse for teenagers with such problems, because at that time in their lives they are usually much more concerned about their appearance than older people, like myself, are" - Name and address supplied