Specific treatment

Wet, inflamed, exuding lesions

(1) Use wet soaks with plain water, normal saline, or aluminium acetate (0^6%). Potassium permanganate (04%) solution should be used if there is any sign of infection.

Treatment guidelines

• Treat the patient, not just the rash

• Complete cure may not be possible

• Be realistic about the problems of applying treatments at home

• Make sure the patient understands how to carry out the treatment

• Advise using emollients and minimal soap

• Provide detailed guidance on using steroids

Acute erythema

(2) Use wet compresses rather than dry dressings ("wet wraps").

(3) Steroid creams should be used as outlined above. Greasy ointment bases tend to float off on the exudate.

(4) A combined steroid-antibiotic cream is often needed as infection readily develops.

(5) Systemic antibiotics may be required in severe cases. Take swabs for bacteriological examination first.

Dry, scaling, lichenified lesions

(1) Use emollients.

(2) Use steroid ointments, with antibiotics if infection is present.

(3) A weak coal tar preparation or ichthammol can be used on top of the ointments. This is particularly useful at night to prevent itching. 1-2% coal tar can be prescribed in an ointment. For hard, lichenified skin salicylic acid can be incorporated and the following formulation has been found useful in our department:

(a) Coal tar solution BP 10%, salicylic acid 2%, and unguentum drench to 100%.

(b) 1% ichthammol and 15% zinc oxide in white soft paraffin is less likely to irritate than tar and is suitable for children.

(4) In treating psoriasis start with a weaker tar preparation and progress to a stronger one.

(5) For thick, hyperkeratotic lesions, particularly in the scalp, salicylic acid is useful. It can be prescribed as 2-5% in aqueous cream, 1-2% in arachis oil, or 6% gel.

It is often easiest for the patient to apply the preparation to the scalp at night and wash it out the next morning with a tar shampoo.

Infection

Remember that secondary infection may be a cause of persisting lesions.

Hand dermatitis

Hand dermatitis poses a particular problem in management and it is important that protection is continued after the initial rash has healed because it takes some time for the skin to recover its barrier function. Ointments or creams should be reapplied each time the hands have been washed.

It is useful to give patients a list of simple instructions such as those shown in the box on the right.

Infected eczema: before (left) and after (right) treatment

Hand dermatitis: hints on management

• Hand washing: use tepid water and soap without perfume or colouring or chemicals added; dry carefully, especially between fingers

• When in wet work: wear cotton gloves under rubber gloves (or plastic if you are allergic to rubber); try not to use hot water and cut down to 15 minutes at a time if possible; remove rings before wet or dry work; use running water if possible

• Wear gloves in cold weather and for dusty work

• Use only ointments prescribed for you

• Things to avoid on unprotected skin:

Shampoo

Peeling fruits and vegetables, especially citrus fruits Polishes of all kinds

Solvents, for example, white spirit, thinners, turpentine Hair lotions, creams, and dyes Detergents and strong cleansing agents "Unknown" chemicals

• Use "moisturisers" or emollients which have been recommended by your doctor to counteract dryness

Further reading

Atherton DJ. Diet and children with eczema. London: National Eczema Society, 1986

Launer JM. A practical guide to the management of eczema for general practitioners. London: National Eczema Society, 1988 Mackie RM. Eczema and dermatitis. London: Martin Dunitz, 1983 Orton C. Eczema relief: a complete guide to all remedies—alternative and orthodox. London: Thorsons, 1990

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