Treat the patient, not just the rash. Many patients accept their skin condition with equanimity but others suffer much distress, especially if the face and hands are affected. Acceptance by the doctor of the individual and his or her attitudes to the disease goes a long way to helping the patient live with the condition.
The common inflammatory skin diseases can nearly always be improved or cleared, but it is wise not to promise a permanent cure.
Be realistic about the treatment people can apply in their own homes. It is easy to unthinkingly give patients with a widespread rash a large amount of ointment to apply twice daily, which is hardly used because: (a) they have a busy job or young children and simply do not have time to apply ointment to the whole skin; (b) they have arthritic or other limitations of movement and can reach only a small part of the body; (c) the tar or other ointment is smelly or discolours their clothes. Most of us have been guilty of forgetting these factors at one time or another.
Dry skin tends to be itchy, so advise minimal use of soap. Emollients are used to soften the skin, and the simpler the better. Emulsifying ointment BP is cheap and effective but rather thick. By mixing two tablespoons in a kitchen blender with a pint of water, the result is a creamy mixture that can easily be used in the bath. A useful preparation is equal parts of white soft paraffin and liquid paraffin. Various proprietary bath oils are available and can be applied directly to wet skin. There are many proprietary emollients.
Wet weeping lesions should generally be treated with creams rather than ointments (which remain on the surface).
Steroid ointments are effective in relieving inflammation and itching but are not always used effectively. Advise patients to use a strong steroid (such as betamethasone or fluocinolone acetonide) frequently for a few days to bring the condition under control; then change to a weaker steroid (dilute betamethasone, fluocinolone, clobetasone, hydrocortisone) less frequently. Strong steroids should not be continued for long periods, and, as a rule, do not prescribe any steroid stronger than hydrocortisone for the face. Strong steroids can cause atrophy of the skin if used for long periods, particularly when applied under occlusive dressings. On the face they may lead to florid telangiectasia and acne-like pustules. Avoid using steroids on ulcerated areas. Prolonged use of topical steroids may mask an underlying bacterial or fungal infection.
Immunosuppressants are a valuable adjunct in severe cases not responding to topical treatment and antibiotics. Ciclosporin is usually given on an intermittent basis, with careful monitoring for side effects. Azathioprine is also used, provided the thiopurine methyl transferase (TPMT) level is normal.
Tacrolimus is an immunosuppressant that has recently become available in two strengths as an ointment. It promises to be a successful treatment but is relatively expensive.
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