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| Treatments for eczema (overview) |
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Reviewed by Dr Victoria Lewis, specialist
registrar in dermatology
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If you suffer from eczema then looking after your
skin is vital to control the condition and reduce the
number of flare-ups you experience. General skin care,
applying moisturisers and avoiding factors that trigger your
eczema are the most important things you can do.
After that, treatment of eczema often involves
several different approaches to control the condition and
all its symptoms, and medicines of several different types
may be used in combination.
Dry skin
Aside
from avoiding trigger factors, the most important element
of eczema treatment is to keep the skin hydrated by
regularly using moisturisers and moisturising soap
substitutes or bath additives. These help to maintain
the barrier function of the skin and reduce itching,
scratching and the penetration of irritants, allergens and
micro-organisms. Moisturisers should be used regularly
even when using other treatments, and when the condition
seems to have cleared up. They have been shown to reduce
the number of flare-ups of eczema that are experienced,
and hence reduce the need for topical
corticosteroids.
Inflammation
Flare-ups of
eczema are traditionally treated with topical corticosteroids. These
reduce inflammation in the skin and are safe and effective
medicines when used correctly. Topical steroids come in
various strengths and the least potent product that is
effective should be used to control the inflammation. Mild
corticosteroids are generally used for children and on the
face and flexures, eg crease of the elbow, behind the
knees etc. More potent corticosteroids may be needed for
adults with discoid or lichenified eczema, or with eczema on
the scalp, limbs, and trunk. Once the inflammation is
under control, topical steroids should be reduced to the
mildest strength needed to control the eczema, or if possible,
stopped. People using topical steroids should be regularly
reviewed by their doctor.
There are two
newer
treatments for reducing inflammation and
controlling flare-ups.
They are Elidel cream, containing pimecrolimus, and Protopic ointment, containing tacrolimus. These treatments do not contain steroids and work in a different way to steroids to suppress the
inflammatory reactions in the skin. They are not
associated with the potential side effects of steroids and
are an important advance in the treatment options for
eczema. However, they are usually reserved for when corticosteroids have not been effective or cause unacceptable side effects. The long-term safety and place in the overall management of eczema of these treatments is still being evaluated.
Lichenification
Lichenification is thickening of the skin with
exaggeration of the normal skin markings, which gives the
skin a leathery, bark-like appearance. It is a result of
repeated scratching and is initially treated with potent
topical corticosteroids. Bandages are sometimes applied over
the topical steroids to treat chronic, lichenified eczema,
as these increase the absorption of steroid into the
thickened skin and break the ‘itch-scratch’ cycle of
eczema. They should only be used under the supervision of a
doctor. The bandages may sometimes contain zinc,
ichthammol or coal tar, used for their anti-itching and
mild anti-inflammatory effects.
Infection
Chronic
eczema may often become infected, particularly with the
bacteria Staphyllococcus aureus, which is found in large
numbers on skin affected by eczema. Eczema in moist areas
of skin such as skin folds is also more susceptible to
fungal infections. Infection worsens the inflammation of
the skin and may require treatment with antimicrobial medicines, such
as antibiotics, antifungals or antivirals. Depending on
the severity of the infection, antimicrobials may be
either applied to the skin or taken by mouth. If the
eczema is frequently infected a doctor may prescribe
moisturisers and moisturising bath additives that also contain
antiseptics to try and prevent infection.
Itching
Many people complain that itching is the worse
symptom of their eczema. Scratching makes itching worse as
it increases inflammation and increases the likelihood of
the skin becoming infected; so short courses of sedating antihistamines are
sometimes prescribed to help reduce severe itching during
acute flare-ups of eczema. These are mainly of value
because they cause sedation, and are usually taken at
bedtime to help sufferers sleep without
scratching.
Unresponsive or very severe eczema
Occasionally eczema may respond poorly or not at
all to all the treatments mentioned above, and in these
cases the patient will be referred to a hospital
specialist. There are various treatments that can
subsequently be tried for very severe eczema.
A course of corticosteroids taken by mouth may
finally bring the inflammation under control,
alternatively immunosuppressant medicines,
such as ciclosporin, may be tried to modify the skin’s
inflammatory responses. These are powerful medicines that
require a good deal of monitoring to minimise the risk of
side effects, but adults and children with very severe
eczema that does not respond to other treatment can
benefit greatly.
Light treatment
(phototherapy) is another option for unresponsive and
severe eczema. People with eczema often comment that
sunshine improves their skin, and light treatment is
sometimes offered in hospital dermatological centres. UVB
light therapy can be extremely beneficial, as can PUVA,
which involves a combination of a drug called psoralen taken
by mouth, followed two hours later by UVA light treatment.
Short-term side effects of light treatment include
sunburn-like reactions, and potential long-term side
effects include premature skin ageing and skin
cancer.
Alternative treatments
Gamolenic acid (evening primrose extract) is an alternative
remedy sometimes used to treat eczema. It is thought that it
might work by increasing the levels of the essential fatty
acid that may be deficient in, and perhaps responsible for
the symptoms of, atopic eczema. However, evidence for the
value of gamolenic acid is inconclusive. Two products
containing gamolenic acid, Efamast and Epogam, used to be
licensed as medicines for the treatment of eczema, however
their product licences were withdrawn in October 2002
following a review by the UK Medicines Control Agency
(MCA) and the Committee on Safety of Medicines (CSM).
These bodies concluded that the available evidence did not
support the current standard of efficacy required for these
products to be authorised as medicines. Evening primrose
oil is still available as a dietary supplement from health
food shops for those who wish to try it, but it is no
longer a licensed medicine for the treatment of eczema. A
three month trial should be long enough to produce
benefits if they are to be any. If you don’t see any
benefits after this time it is probably not worth wasting
your money.
Traditional Chinese
herbal medicines are another alternative treatment for
eczema, though at present it is unclear whether they do more
harm than good. Results from several studies have
suggested that patients with atopic eczema benefit from
these therapies, but there is also concern about the side
effects of some of the herbs on the liver and heart. Cases
of corticosteroids being illegally added to Chinese herbal
creams have also been reported, and this is hard to
monitor as the production of such herbal products is not
standardised or regulated. For these reasons it is
recommended that Chinese herbal remedies should only be
used under specialist supervision.
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Based on a text by Helen Marshall, pharmacist
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Last updated 05.04.2007
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