MD. M.R.I.P.H.H (UK)
Dermatology Department ,PIMS
Islamabad, Pakistan

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It can be discussed under the following heads:

For Chronic cases.
For Acute Flares of the disease.

First we will discuss :

Treatment of the Chronic cases

There can be the following modalities of treatment :

1. Hydration :

Your skin is dry, not because it lacks grease or oil, but because it fails to retain water. Therefore, to correct dryness, water is added to the skin, followed by a grease or oil-containing substance to hold the water in. This can be done by soaking the affected area, in a basin, bath, or shower, for 15-20 minutes using moderately warm water. Then, remove excess water by patting with a soft towel, and immediately apply a water-in-oil or fatty hydrophobic base (examples: Aquaphor, Eucerin, Crisco, white petroleum). Use of petroleum or Crisco without first trapping in water is not effective, since it does not hydrate the skin, but only prevents further water loss. You should bathe and lubricate at least once a day, and preferably twice for optimum hydration. Some patients find it soothing to add colloid substances--such as oatmeal (Aveeno)--to the bath water. We don't recommend using bath oils--since they give a false sense of lubrication, and actually make the bathtub slippery. Most patients find that two or three additional applications of agents that hydrate the skin (examples: Eucerin, Aquaphor, Lubriderm, Vaseline Dermatology Lotion, Moisturel, and Curel) help keep their skin moist.

2. Tar Preparations

Tars and extracts of crude coal tar are often used to reduce the amount of topical steroids needed in chronic maintenance of eczema. Five percent LCD (Liquor carbonis detergens) in a cream base such as Aquaphor has been found to have acceptable cosmetic properties. Tar gel products (Estar Gel and Psorigel) are available, but they contain alcohol and may cause burning and irritation on already red and inflamed skin. Tar gels are best applied under a hydrating agent.

3. Steroids

Topical steroids are frequently used to treat flares of eczema, so it is important you understand how and when to use this potent drug. When used topically, as a cream or ointment, it helps keep down the inflammation and itching. Let your doctor know your preference for cream or ointment, since each has its advantages and disadvantages. Sprays and lotions are best used on scalp or other hairy areas.

Topical steroids should be used immediately after a bath or a soak to increase its uptake by the skin. Do not use topical steroids more than twice a day. Your pharmacist can provide topical steroids in half-pound or pound quantities upon request to reduce the unit cost.

Hydrocortisone ointment or cream can be used for eczema in infants and young children, or in skin folds in adults. More potent topical steroids should not be used on thin-skinned areas of the face, neck, axilla, and groin. Supervised courses of medium potency topical steroids such as 0.1 percent triamcinolone or 0.025 percent fluocinolone used one to two times daily are safe and effective for flares of eczema on other parts of the body. Adverse effects of topical steroids include thinning of the skin (atrophy), a change in the color of some skin (depigmentation), and acne-like eruptions.


4. Antibiotics

Systemic antibiotics are often necessary to decrease the irritation caused by the presence of bacteria on the skin. Such bacteria can cause irritation even without overt infection. However, if you are treated with erythromycin and also have asthma and are taking theophylline, your doctor will have to monitor your serum theophylline concentration and probably adjust your drug dose, since erythromycin slows theophylline metabolism. Other antibiotics used may include dicloxacilline or clindamycin. In acute flares, treatment usually ranges from 14 to 28 days. Chronic maintenance antibiotics may be used if you develop infections repeatedly. Topical antibiotics cannot be recommended and antibacterial cleansers may worsen the condition.

5. Antipruritics

Pruritis, or itching, is often the most aggravating of all your eczema symptoms. Some relief may be provided by systemic antihistamines (hydroxyzine diphenhydramine, chlorpheniramine, or promethazine) and anti anxiety drugs (doxepin or amitriptyline). The antihistamines--which probably reduce scratching mainly through tranquilizing and sedative effects-- should be used on a regular basis for optimal results. If nighttime scratching remains severe, your doctor may want to prescribe a sedative. Scratching can be minimized by cutting nails, and using cotton gloves at night. For children, knee-high socks are better than gloves, because they are harder to accidentally pull off during sleep.

The topical use of antihistamines and local anesthetics should be avoided because they are ineffective and because of their possible allergic effects.

6. Corticosteroids

Oral corticosteroids should be avoided because of the seriousness of their side effects and the potential for severe flares of eczema when they are discontinued. Intensified skin care will help to suppress the flaring of the eczema during a taper from oral steroids.

II. Therapy of Acute Flares

Most doctors prefer you attempt to treat acute flares at home. However, your doctor may suggest hospitalization simply because it may be necessary to break the cycle of chronic inflammation, or other problems that are exacerbating the illness. Frequently, five or six days of vigorous in-hospital treatment care can result in a dramatic clearing of the eczema. Food tests, allergy skin testing, and the development of an outpatient therapy plan can all be done during the hospitalization.