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How to administer steroid treatment for atopic eczema

A growing number of people are atopic. One in five preschool children and one in 10 adults currently have atopic eczema. Persuading a patient with eczema (or the carer of a child with eczema) to use a topical steroid can lead to one of the more challenging consultations you will experience, but time spent educating and explaining at this stage will pay dividends.
Mild and moderately potent topical steroids are associated with few side-effects when used correctly, but care is needed with potent preparations. Regular review of the patient and monitoring of repeat prescriptions are necessary, especially when potent and very potent preparations are being used. An understanding of the stepladder of topical steroids and their indications, together with the available vehicles and their differing properties, will help you become more confident in treating your patients with eczema.

Potency ladder
The potency of a steroid preparation depends on the drug's innate properties and its concentration. The vehicle used (eg, cream, ointment, lotion) will vary the rate of absorption. In the British National Formulary topical steroids are categorised as "mild potency", "moderate potency", "potent" or "very potent" (see Table 1).

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This forms a ladder of drug potency that can be ascended and descended according to the severity of the eczema and the response to treatment. The risk of side-effects parallels the strength of the steroid, the length of application and the type of vehicle used.
It is best to familiarise yourself with one or two of each of the different potency topical steroids, and use them in a stepwise manner. The aim should also be to enable your patients to self-manage their condition, giving thorough oral and written information so they can do this. Provide them with a range of different potency preparations and clear instructions on how to move up and down the ladder of potencies. Try not to switch treatment regimens too frequently.
Initial management should be with an intensive regimen of emollients, but if there are two or more areas of red inflamed eczema add in an appropriate topical steroid. For mild-to-moderate eczema begin with 1% hydrocortisone, unless the skin is thickened (palms, soles, lichenified chronic eczema), when a moderate potency can be used. If the skin is well hydrated with emollients, the lower-potency topical steroids will be much more effective. Look for signs of infection (sudden onset of flare, impetiginous exudate) and add an oral antibiotic if required.

Duration of treatment
Guidelines for duration of treatment vary, with the British Association of Dermatology advising twice daily application of a mild/moderate topical steroid for up to 10-14 days for acute eczema. In more chronic situations where there is lichenification a mild-potency steroid can be used for four to six weeks. Randomised controlled trials have indicated that there is probably no difference between the efficacy of once-daily and twice-daily regimens. Potency 3 and 4 preparations should not be used for more than seven to 10 days.
By the end of a week to 10 days, if the prescribed treatment regimen has not been effective, then you can step up to a more potent steroid. Again look for signs of infection and send a swab for bacteriology if indicated. If the treatment has been effective then step down to the next less potent steroid rather than withdrawing steroid treatment abruptly, to avoid a rebound flare.
An alternative regimen favoured by some dermatologists is to achieve control of the situation rapidly by using a higher-potency steroid for a week or so and then stepping down. In this way the patient realises that steroids are effective and will be less worried about future use.
Cutaneous side-effects of potent and very potent topical steroids may be noticeable within two weeks of starting treatment, so only provide enough for a maximum of two weeks before review. The quantity needed can be calculated using the finger-tip unit rule. Steroid-induced skin atrophy occurs when the epidermis, and particularly the dermis, become thinned by reduction in collagen fibres, so small blood vessels lose their support. This appears as transparent fragile skin with visible blood vessels and easy bruising. At this stage it is potentially reversible, but if the dermis completely loses its elasticity then striae (red areas like stretchmarks) and telangectasiae (enlarged small blood vessels) form, and these are permanent. These irreversible changes take several weeks to develop, and can be avoided by using stronger steroids (from potency groups 3 and 4) for no more than a week or two at a time. Extra care should be taken in areas of thin skin (face, eyelids, axillae, perineum) or when the area is occluded.
In a primary care setting only mild and moderately potent steroids should be used in children. If you use a moderate-strength steroid in a child you must review regularly for local and systemic side-effects, and a growth chart should be kept.

Choice of emollient
Choosing which type of preparation to use will depend on the nature of the eczema and the area of the body involved. Creams should be chosen for moist or weepy areas, while ointments are more occlusive and are used for dry, lichenified or scaly eczema.
Lotions are useful for exuding lesions and hair-bearing areas, such as the axillae. Scalp applications are alcohol-based, evaporating to leave the active ingredient in place. Use an ointment in preference to a cream as much as possible.
The choice of emollient (creams, ointments, soap substitutes, bath oils) is a very individual one for both patient and nurse. Use what you are familiar with and you know the patient will use. Emollients are available in small sample packages, and you can give the patient several to take away and try at home. Emollients available in pump dispensers are less likely to be contaminated by microorganisms with repeated use. Most importantly, give correct instructions for use. Emollients should be applied frequently and liberally every three to four hours, and are most effective when the skin is moist (after a bath or shower).

Quantity
Most patients and nurses underestimate the quantities of emollients required, with the recommended quantities used in generalised eczema being 600g/week for an adult and 250g/week for a child. Intensive use of emollients is steroid-sparing, and patients should know that the ratio of emollient use to steroid use should be 10:1. If you are prescribing a topical steroid, advise application at least 30 minutes before the emollient so that the effect of the steroid is not diluted.

When to apply
Bathing and showering are ideal opportunities for applying emollients and removing microorganisms from the skin, especially for children. Irritant soap, bubble bath and shower gels can be substituted by preparations such as aqueous cream and emulsifying ointments, and oils can be added to the bathwater, although avoid the use of antibacterials as these have no proven benefit. 

Conclusion
Finally, don't be too cautious with treatment, as most failures of treatment in eczema are related to inadequate application of medication. Take the opportunity to review your patients regularly to see what works best for you and them.

Resources

British Dermatological Nursing Group
W:www.bdng.org.uk

National Eczema Society
Hill House Highgate Hill London N19 5NA
T:020 7281 3553 Helpline:
0870 241 3604
E:helpline@ eczema.org
W:www.eczema.org

Skin Care Campaign
The SCC represents the interests of all people with skin disease in the UK W:www.skincare campaign.org