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PLAN
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REFLECT
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cpd module
CONTINUING
PROFESSIONAL
DEVELOPMENT
PROGRAMME
ODULE
This module has been accredited by the College of Pharmacy Practice as suitable for use by pharmacists as part of their continuing
professional development cycle. Complete the record form on page viii for inclusion in your CPD portfolio
MODULE
Epidermal barrier
GOAL:
OBJECTIVES:
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VIEWING MEDICINE
Complications
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cpd module
become life-threatening. If eczema herpeticum
is suspected, a patient must be referred to
his/her GP immediately. Parents should be
warned of the dangers of contact with anyone
who has herpes simplex or cold sores.
Diagnosis
The diagnosis of eczema is based on the finding
of itchy skin plus three or more of the following:
Onset before two years of age
History of dry skin
History of eczema in the skin creases (and also
the cheeks in children under 10 years of age)
Visible flexural eczema (inside elbows, behind
knees or involvement of cheeks, forehead and
outer limbs in children under four years of age)
Personal history of other atopic disease (or
history of any atopic disease in a first-degree
relative if the child is aged under four years of
age).
Several other conditions could be mistaken
for eczema. Scabies can look like eczema and the
severe itching that accompanies established
scabies infestation adds to the confusion.
Scabies (and head lice) can also precipitate local
flare-up of eczema. Psoriasis can look like
eczema, but psoriasis plaques are usually found
on extensor (outside) surfaces whereas eczema
more commonly affects flexor (inside) surfaces.
Fungal infections and rosacea can also mimic
the appearance of eczema. If the diagnosis of
eczema is uncertain, the patient should be
referred to a doctor.
Mechanism/comment
Abrasive clothing
Psychological stress
Caused by life events, disease, etc.
Food hypersensitivity
Cows milk, eggs, soya, wheat, fish and nuts
Inhaled antigens
House dust mites
Animal dander
Choosing emollients
Effective treatment depends on the careful
selection of products to match patients needs
and preferences. Finding the most suitable
emollient is usually a matter of trial and error.
In general, greasier, oil-based products are
more efficacious but there is often a trade-off
between efficacy and cosmetic acceptability
(smell, consistency, etc.). A patient may require
different emollients for different areas of the
body; for example, a heavy emollient for dry skin
on the limbs and a lighter product for the face.
Patients may also be prepared to use a richer
(greasier) emollient at night than during the
day. Richer products may also be needed in
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interchangeable
Atopic eczema is the commonest form of eczema;
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Formulation considerations
Greasier emollients are harder to spread and
more occlusive. Lighter emollients are easier
to spread and less occlusive. Emollient lotions
are dilute oil-in-water emulsions (creams) or
emulsions formulated with more spreadable
emollients. In addition to the basic ingredients,
many emollient products also contain other
therapeutically active substances.
Humectants
Humectants are agents that attract water. In
emollients they work by drawing water from the
dermis into the epidermis (rather than by taking
it from the atmosphere). Common examples
include urea, glycerine, polyethylene glycol and
lactic acid. Studies have shown that the inclusion
of urea increases hydration of the horny layer and
improves epidermal barrier function. Emollient
products that contain humectants are particularly useful for rehydrating dry, flaky skin.
Use liberally (500g per week for an adult is not unusual). Apply gently but quickly with clean hands. Leave
at least half an hour between emollient application and any topical steroid application to avoid dilution of
the steroid or its spread to unaffected areas. Warm the emollient (e.g. by standing it in the airing cupboard
beforehand) so that it can be applied more easily. If itching is a major problem, cool the emollient by storing it
in the fridge. Apply after a bath and several times during the day (ideally three to four times a day, but at least
twice). Use additional emollient in extreme weather.
Emollient soap substitute
Use emollient soap substitute whenever washing hands and before getting into a bath or shower. Conventional
soaps and wash products can be very drying. Emollient wash products (such as aqueous cream and emulsifying
ointment) cleanse the skin effectively, although they do not lather like soap. Apply to dry skin then rinse off with
water. Never use ordinary soap, moisturising soap or bubble bath.
Emollient bath oil
Emollient bath products are another means of applying emollients. They leave a fine film of emollient on the
skin after bathing. Add 5ml of oil to an adult bath and 2.5ml to a baby bath. The bath should be warm but not
too hot, as this exacerbates itching. Pat skin dry, do not rub, as this may also exacerbate itching. Use a bath mat
to prevent slipping.
Lanolin
Colloidal oatmeal
Colloidal oatmeal is very finely ground oatmeal
that forms a hydrophilic matrix (e.g. Aveeno).
This makes a cooling application that also
appears to have some anti-pruritic effects for
the user.
Macrogols
Macrogols are water-soluble, ethylene glycol
polymers that are commonly used in
dermatological formulations. Lauromacrogols
are said to have a mild local anaesthetic effect
and can be useful in relieving itching. Mixed
lauromacrogols (polidocanol) are included in
Balneum bath oils, Balneum Plus cream and
some of the Eucerin range for this reason.
Antiseptics
Antiseptics are included in some products (e.g.
Oilatum Plus). They are said to be helpful in
controlling flare-ups.
Eczema can cause untold misery especially for babies, young children and their parents...
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Topical corticosteroids
Acute flare-ups of eczema should be settled
using topical corticosteroids, which inhibit the
production and action of inflammatory
mediators so that inflammation is reduced and
itching relieved. The least potent corticosteroid
to produce the required effect should be
prescribed. However, this does not mean that
treatment should be started with the weakest
available topical corticosteroid. A product
should be selected to match the severity of the
Reflection exercise
Five-year-old Wayne has had atopic eczema since he
was six months of age. His eczema mainly affects his
face and neck, the inside of his elbows and the backs
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Anti-infective agents
Prompt treatment of infected eczema is an
important step in controlling flare-ups.
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Other treatments
she often does not need it because the Eumovate is a cream anyway. She has not used the Doublebase very
often because it felt quite greasy when she first tried it. She adds that itching is the worst aspect of this flareup and it gets worse in bed at night. She often scratches her wrists and ankles during her sleep and wakes to
find bloodstains on the sheets. She washes with ordinary soap or whatever is handy in the bathroom.
Medicines use issues
Proposed action
skin supple
Immunomodulators
In recent years, topical immunomodulators have
been introduced to treat atopic eczema. Topical
tacrolimus or pimecrolimus are useful when
there is a risk of serious side-effects, or when
eczema cannot be controlled, with topical
corticosteroids. The long-term safety of these
agents has yet to be established, and at present
treatment
Further reading
J 2004;273:351-353
Making the most of emollients. Clark CM and Hoare
C. Pharm J 2001;266:227-229
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Competences
C3c, C3e
The module addresses the way in which the MUR process can be
used to help patients with chronic eczema
Further information
The National Eczema Society can be found at:
Hill House, Highgate Hill, London N19 5NA.
Eczema Help Line: 0870 241 3604 (Mon-Fri 8am
-8pm). Website: www.eczema.org
References
1. Prodigy guidance: Eczema atopic: www.prodigy.nhs.uk/guidance.asp?gt=Eczema%20-%20atopic
2. Cork MJ. The importance of skin barrier function. J Dermatol Treatment 1997;8:S7-S13
3. Palmer CN, Irvine AD, Terron-Kwiatkowski A et al. Common loss-of-function variants of the epidermal barrier
protein filaggrin are a major predisposing factor for atopic dermatitis. Nat Genet. 2006;38:441-446
4. Cork MJ, Timmins J, Holden C, Carr J, Berry V, Tazi-Ahnini T, Ward SJ. An audit of adverse drug reactions to
aqueous cream in children with atopic eczema. Pharm J 2003;271:747-748
5. Mahrle G, Wemmer U, Matthies C. Optimised interval treatment of eczema with fluprednidene:
a multicenter double-blind study. Zeitschrift fr Hautkrankheiten 1989;64(9):766-8,773-4
6. Charman C and Williams H. The use of corticosteroids and corticosteroid phobia in atopic dermatitis.
Clinics in Dermatology 2003;21:193-200
7. NICE Technology Appraisal Guidance TA82: Tacrolimus and pimecrolimus for atopic eczema. August 2004
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ASSESSMENT
QUESTIONS
Activity/development completed
(Act)
ATOPIC ECZEMA
1. Which statement is TRUE
regarding eczema in the UK?
It affects:
a.
b.
c.
d.
a. Absorption is greater
through thin skin, such as
that of the face or flexures
b. Treatment for a flare-up
should be started as soon
as possible
c. Emollient treatment
should continue when
steroids are started
d. One finger-tip unit should
be used to cover an area
equivalent to the flat of
one hand
5. Humectants in emollients
exert their action by:
a. Attracting water from the
surrounding atmosphere
b. Reacting with filaggrin to
release water
c. Attracting water from the
dermis
d. Breaking down to release
water
Date:
How have I put this into practice? (Provide examples of how learning has been applied what did you do differently as a result?)
(Evaluate)
If as a result of completing your evaluation you have identified another new learning objective, start a new cycle
this will enable you to start at Reflect and then go on to Plan, Act and Evaluate. This form can be photocopied to
avoid having to cut this page out of the module.
a.
2.
a.
3.
a.
4.
a.
5.
a.
6.
a.
7.
a.
8.
a.
b.
b.
b.
b.
b.
b.
b.
b.
c.
c.
c.
c.
c.
c.
c.
c.
d.
d.
d.
d.
d.
d.
d.
d.
Name on card_______________________________
Visa
Mastercard
Switch/Maestro
Processing of answers
Completed answer sheets should
be sent to Precision Direct
Marketing, Precision House, Bury
Road, Beyton, Bury St Edmunds
IP30 9PP (tel: 01284 718918;
fax: 01284 718920;
email: cpd@precisiondm.com),
together with credit/debit
card/cheque details to cover
administration costs. This
assessment will be marked and
you will be notified of your result
and sent a copy of the correct
answers. The examiners decision
is final and no
additional
correspondence
will be entered
into.
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