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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

CURRENT THINKING ON...

MODULE

137 ATOPIC ECZEMA

Welcome to the one hundred and thirty seventh

module in the Pharmacy Magazine Continuing
Professional Development programme, which looks at
atopic eczema. It is valid until February 2010.
Continuing professional development (CPD) is a
mandatory requirement for all practising pharmacists.
Journal-based educational programmes (unscheduled
learning) are an important means of keeping up-todate with clinical and professional developments
and will form a significant contribution to your
ongoing CPD.
Before reading the module, assess your learning
needs by answering the questions below. After
reading the module, complete the record form on page
viii for inclusion in your CPD portfolio. You can also
test your knowledge by answering the multiple choice
questions and sending your answers to the address
shown. A 3.75 marking charge applies to each
module.

Self-assess your learning needs:

How should atopic eczema be managed in
primary care?
What is the therapeutic role of the calcineurin
inhibitors tacrolimus and pimecrolimus?
When can topical corticosteroids be sold over
the counter?
This module supports the following CPD
competences: C1a, C1b, C1c, C1d, C1f, C3c and C3e.
More details on pvii

FOR THIS MODULE

Contributing author: Christine Clark, PhD, MSc, BSc, FRPharmS,

freelance medical writer
Introduction

Epidermal barrier

Eczema is an inflammatory skin condition that

affects all age groups. It is the commonest skin
condition in the UK affecting 15-20 per cent
of children and two to 10 per cent of adults.
There has been a substantial increase in the
prevalence of atopic eczema over the past 30
years and, while there are many clinical variants
of eczema, the common feature is red, itchy,
sore, inflamed skin. Eczema accounts for
around 30 per cent of GP consultations for skin
disease and 14 per cent of consultations in
hospital dermatology clinics.
Statistics, however, cannot convey the
discomfort and misery endured by sufferers of
eczema and their families. Inability to sleep due
to severe itching means that schoolwork and
home life are disrupted while, for some people,
eczema affecting the hands also interferes with
their ability to work. Then there are other
peoples reactions to the condition often
prompted by the erroneous belief that eczema
is contagious.

Skin is made up of the dermis and the epidermis

(the surface layer). The dermis is 3-5mm thick
and contains blood vessels, hair follicles and
sweat glands. The epidermis varies in thickness
from about 0.06mm on the eyelids to 0.8mm
on the palms and soles, and comprises mainly
keratinocytes (skin cells) in various stages of
development. Melanocytes and Langerhans
cells are also located in the basal layer.
The epidermis is composed of four layers
of densely-packed keratinocytes, which are
formed continually in the basal layer and
move gradually upwards to the horny layer

Management of eczema in primary care

The management of eczema in primary care is based on:
Identification and avoidance of trigger factors
Regular use of emollients
Intermittent use of topical corticosteroids and
antibiotics to control flare-ups
Referral for specialist care when conventional
measures are ineffective1

GOAL:

To provide an overview of current thinking on the

management of atopic eczema in the community

OBJECTIVES:

After studying this module, pharmacists

should be able to:
Describe the management of atopic eczema in primary care
Assess whether treatment is being used appropriately
Explain the risks and benefits of topical corticosteroid
treatment.

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(stratum corneum). As they move they change

progressively from plump, nucleated cells to
flattened, dead cells that are shed. The whole
process takes about 28 days.
A lipid substance is formed by the breakdown
of filaggrin in the epidermal cells and extruded
into the intercellular space. If you think of the
horny layer as a brick wall, the cells (now known
as corneocytes) are the bricks and the lipids are
the mortar. The corneocytes contain a waterretaining substance called natural moisturising
factor (NMF), which ensures that water is held
in the cells. Cells with a high water content swell
and press tightly against each another, with no
gaps. The cells are also linked by protein bridges
known as corneodesmosomes.
Corneocytes are shed from the uppermost
surface when the corneodesmosomes are cleaved
by skin proteases. Thus, although cells are
continuously shed from the upper surface of
the horny layer, the deeper layers are firmly held
together through the combined actions of the
barrier lipids, NMF and the corneodesmosomes.

Known as the epidermal barrier, this serves to

prevent both excessive water loss from healthy
skin and the ingress of allergens and irritants.
In atopic eczema, the intercellular lipids are
not formed normally and, as a result, the
epidermal barrier is less effective2. There is
increased water loss from the stratum corneum
and the cells of the stratum corneum shrink,
with cracks opening up between them. The
result is dry skin, which can neither retain water
effectively nor prevent the ingress of irritants or
allergens. Two genetic variations have been
identified recently that go some way towards
explaining these changes.
Some people have high levels of the skin
protease, stratum corneum chymotryptic
enzyme (SCCE) and this is associated with
atopic eczema. Moreover, raising the skin pH,
for example by washing with soap, increases skin
protease activity. Raising the pH from 5.5 to 7.5
(as happens when washing with soap) results in
a doubling of protease activity. Another genetic
variation results in filaggrin deficiency. This is

Skin and water...

The healthy stratum corneum has a relatively high
water content typically 15-20 per cent and is
elastic and pliable. Dry skin (xerosis) is the result of
abnormal water loss. When the water content of
the stratum corneum falls below 10 per cent, fine
scaling is visible and the skin feels rough and dry.

also associated with atopic eczema and is

thought to be due to impaired formation of skin
barrier lipids3.
These changes can also be seen in normal
skin when some of the epidermal lipids are
removed by repeated use of surfactants or
solvents. The use of soap not only removes
natural oils from the skin, making it feel dry, but
also increases shedding of skin cells. Individuals
with atopic eczema are more sensitive to the
effects of soap and surfactants than is usual, and
even their apparently normal skin has a lower
threshold for irritation than that of non-sufferers.
Current thinking suggests that the irritants
and allergens that penetrate the weakened
epidermal barrier trigger immune responses
including the release of pro-inflammatory
cytokines. The problems are further exacerbated
by the itch-scratch cycle. Scratching relieves
itching temporarily but further damages the
skin and can itself trigger the release of more
inflammatory mediators, thereby increasing
inflammation and itching and perpetuating
the cycle.

Complications

Severe case of infected eczema affecting the hand of a child

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A common complication of atopic eczema is

bacterial infection with Staphylococcus aureus,
leading to impetigo. Eczematous skin is almost
always colonised with S. aureus but treatment is
only required when there is evidence of infection
(e.g. worsening inflammation, weeping, crusting).
People with eczema are more susceptible to
viral infections such as molluscum contagiosum
and viral warts. Infants and young children
with eczema can develop widespread lesions if
infected with herpes simplex. This condition,
known as eczema herpeticum, involves clusters
of blisters on the lesions, sudden obvious
worsening of the eczema and fever, and can

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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.

Treatment strategies: Avoidance of triggers

An important element of eczema management
is the avoidance, as far as possible, of factors that
can trigger an eczema flare-up. Helping people
to identify their own or their childs trigger
factors is an important step in supporting selfmanagement of the condition (see Table 1).

Effective use of emollients

Emollients are the mainstay of eczema
treatment. Appropriate emollient products used
correctly can help keep the skin in good
condition, restore suppleness and pliability,

Table 1: Trigger factors for atopic eczema

Factor

Mechanism/comment

Irritants Soaps and detergents

Removal of lipids from skin/activation of skin proteases

Toiletries and cosmetics

(Also perfumes and preservatives; see above)

Abrasive clothing

Direct physical irritation due to scratchy texture

Extremes of temperature or humidity

Drying effect on skin

Psychological stress
Caused by life events, disease, etc.

Some people respond with habitual scratching,

which exacerbates the eczema

Food hypersensitivity
Cows milk, eggs, soya, wheat, fish and nuts

Only likely to be a significant factor in around

10 per cent of children, mainly under three years

Inhaled antigens
House dust mites

Allergens in house dust mite faeces

Animal dander

Allergens in animal saliva

Moulds and pollens

Plant or mould allergens

Source: Information in Prodigy guidance

reduce steroid requirements and improve

cosmetic appearance. Although there is a lack
of good quality clinical trial evidence concerning
the use of emollients, there can be little doubt
about their usefulness in eczema. Emollients are
used to restore the integrity of the epidermal
barrier. An emollient forms an oily layer over the
skin that prevents the evaporation of water. The
water trapped in the stratum corneum passes
into the corneocytes, which swell and close up
intercellular gaps. In addition, emollients can
penetrate deep into the stratum corneum and
mimic the barrier effects of the deficient lipids.
There is also some evidence that emollients
might have indirect anti-inflammatory actions.

Complete emollient therapy

Emollient products include creams, ointments,
lotions, bath oils and soap substitutes. In order
to be effective, emollients need to be applied
frequently and generously to ensure that the
skin is well moisturised at all times.
Many dermatologists recommend complete
emollient therapy an approach based on
the premise that the patients skin should be

protected from soap and detergents as far as

possible and treated with emollients as
frequently as possible. It involves the application
of emollient creams or ointments, use of bath oil
when bathing or showering, and routine use of
an emollient soap substitute, backed up with
education on how to use them (see Table 2).
Soaps and detergents, especially bubble baths,
must be avoided at all times.

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

Eczema key points

The terms eczema and dermatitis are

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other clinical variants include seborrhoeic

eczema, discoid eczema, pompholyx eczema,
asteatotic eczema, irritant contact eczema and
allergic contact eczema
The common clinical feature is red, itchy,
inflamed skin
Acute eczema can be accompanied by
exudation and crusting, while chronic eczema
lesions are dry, lichenified and fissured
The severity of eczema often varies from day
to day

interchangeable
Atopic eczema is the commonest form of eczema;

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the winter to combat the drying effects of

cold weather and central heating.
Patients, including children, should be
encouraged to try a number of emollients to help
them to find those they like best. Children with
eczema often complain that the worst aspect
of the disease is the creams. Some hospitals
have now developed trial kits of emollients
specifically for this purpose.

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.

Table 2: Complete emollient therapy

Emollient cream or ointment

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.

Essential fatty acids

Lanolin

Topical application of essential fatty acids (EFAs)

is helpful in reducing irritation and dryness for
some people with eczema. This is thought to
be linked to the observed deficiency of delta-6desaturase in some people with the condition.
This enzyme is responsible for the conversion of
the essential fatty acid, linoleic acid, to linolenic
acid a key step in prostaglandin elaboration.
Although the marketing authorisation for
oral supplements of EFAs has been withdrawn,
a topical preparation (Gammaderm) is
available.

Lanolin is a good emollient and, contrary to

popular belief, is a very weak sensitiser. Large
studies have shown that the true incidence of
lanolin sensitivity is actually very low. Most
lanolin-containing products now use highlypurified, hypoallergenic lanolin, which is welltolerated.

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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Allergens and irritants

Some emollients contain potential allergens that
can exacerbate eczema (see lists in BNF; Prodigy
guidance). Creams and lotions, being oil-inwater emulsions, usually contain preservatives,
such as benzyl alcohol and hydroxybenzoates
(parabens) to prevent bacterial growth.
Recent findings suggest that aqueous cream
may be unsuitable as a leave-on emollient for
many people, although satisfactory as a wash-off
product4. This has been attributed to the welldocumented irritant effects of the anionic
surfactant, sodium lauryl sulfate. (Aqueous
cream also contains chlorocresol or phenoxyethanol, which may contribute to the irritation.)
Patients should always test a new product on
a small area of skin before using it on large or
sensitive areas.

Emollients and topical steroids

Studies have shown that the correct use of
emollients can have a steroid-sparing effect i.e.
the same effects can be achieved with lower
doses of steroid5. It is sometimes useful to point
this out to steroid-phobic people who are
apprehensive about using steroids because of
lurid stories in the popular press. As a rule of
thumb, patients should use about 10-times
as much emollient as a topical corticosteroid
preparation.

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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Finger-tip unit for steroid use

disease. In general a short burst of treatment

with a potent or moderately potent steroid is
preferable to protracted under-treatment.
On areas where the skin is thin, such as the
face, genitals and flexures, a mildly-potent
steroid (e.g. hydrocortisone) should be used.
Mild-to-moderate eczema in other areas of
the body can be treated for one to two weeks
with a moderately potent corticosteroid (e.g.
clobetasone butyrate 0.05%). Areas where the
skin is thick (e.g. palms, soles, scalp) may require
potent steroids. Infants younger than one year
of age should only be treated with a mildly
potent preparation, such as hydrocortisone
ointment 1%.
Steroids should be applied once or twice a
day. Ointments are suitable for dry, lichenified
or scaly lesions, whereas creams are more
appropriate when the skin is oozing and infected
so that the infected area is not occluded.

Pharmacists and topical corticosteroids

Community pharmacists can sell some topical
corticosteroids for eczema in the following
situations:
Some hydrocortisone 1% creams and ointments
in cases of mild-to-moderate atopic eczema. They
are useful to treat flare-ups, but should not be
used for more than one week. Patients who have
not previously been diagnosed with atopic

eczema should be referred to their GPs, as well

as patients whose condition is widespread
and/or severe. Hydrocortisone cannot be sold
for use in children under 10 years of age or in
pregnant women.
Hydrocortisone 1% cream and ointment can
be sold for use in children under 10 years of age
and pregnant women on medical advice (i.e. if
it has been recommended to the patient by the
GP, who has not provided a prescription for it.)
Clobetasone butyrate 0.05% cream may be
sold for the short-term treatment and control of
small patches of atopic eczema in adults and
children over 12 years of age.
The local and possible systemic side-effects
of corticosteroids are well-recognised but
often exaggerated. Side-effects generally only
occur following the incorrect use of potent
corticosteroids over a long period of time. The
incidence and severity of side-effects are
determined by the area to be treated, the
thickness of the skin, the potency of the
preparation and the duration of treatment.
Greater absorption occurs when the skin is
damaged and raw.

Anti-infective agents
Prompt treatment of infected eczema is an
important step in controlling flare-ups.

Topical corticosteroids key points

Corticosteroid treatment for eczema flare-up
should be started as soon as possible so that the
inflammation can be settled before there is
extensive damage
The fingertip unit (FTU; see picture) can be used
as a guide application. One FTU is sufficient to
cover an area equivalent to the flat of two hands.
Many patients have difficulty understanding the
FTU concept and may be better advised to apply
sufficient steroid to create a faint sheen on the skin
Sufficient topical corticosteroid cream should be
supplied to treat the flare-up until it is completely
resolved (see BNF for suggested quantities)
Patients should always be reminded not to use a
steroid cream or ointment as an emollient
Patients often confuse potency with
concentration
Some parents of children with eczema are
steroid phobic as a result of scare stories in the
press and will avoid using steroids6

of his knees. You know that his mother has always

been diligent in applying regular emollients and
hydrocortisone intermittently and his eczema has

skin for life.

What advice might you offer Waynes mother?
What points would you emphasise?

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tells you that she is worried about this because she

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and large quantities of emollients. Waynes mother

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has prescribed clobetasone butyrate 0.05% cream

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preventing him from sleeping properly. His doctor

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severe flare-up affecting all the usual sites, which is

been reasonable well-controlled. Wayne now has a

What kind of regimen could you suggest?

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Moderate to severe bacterial infection with S.

aureus, when the skin is weeping or excoriated,
should be treated using oral antibiotics, such
as flucloxacillin or erythromycin. They should
only be used in short courses of about seven
days to minimise the risks of resistance and
sensitisation. There is no evidence that topical
antibiotic/topical corticosteroid combination
products are any more effective than the
corticosteroid alone and, given the risk of
development of bacterial resistance, they cannot
be recommended.

MUR case study

Many people with eczema do not experience the full benefits of treatment. Sometimes this is because they
have misunderstood how to use the treatment and sometimes because they do not have the right products or
right quantities. Such patients could benefit from an opportunistic MUR, as the following example shows.
Lorna is a 25-year-old office worker. She had eczema as a child but thought she had grown out of it. Recently
there has been considerable upheaval at work as the company has downsized and a number of her colleagues
have been made redundant. Lornas eczema started to flare up again. She developed itchy, inflamed patches on
her hands, the insides of her wrists, around her ankles and at the back of her neck. Her GP prescribed Eumovate
cream, aqueous cream and Doublebase. She tells you that she is disappointed with the results and asks if she
can buy anything stronger over the counter. She apparently has appropriate treatment but it does not seem to
be working so you invite her for a MUR.
At the MUR she tells you that she uses the Eumovate twice a day and also the aqueous cream, although

Other treatments

she often does not need it because the Eumovate is a cream anyway. She has not used the Doublebase very

Sedative antihistamines (e.g. promethazine,

alimemazine [previously known as trimeprazine] or hydroxyzine) are helpful for some
patients on some occasions. They are taken at
night and are reputed to help by reducing the
itching and allowing the patient to have a good
nights sleep. It should be noted that only
hydroxyzine is licensed for use in babies of six
months and older. Neither promethazine nor
alimemazine is licensed for use in children
under two years of age.

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

Topical corticosteroid applied correctly but needs to

Advise to continue use but emphasise the importance

be used together with emollients

of using with emollients

Using insufficient emollient not enough to combat

Explain that emollients should be applied after each

dryness and irritation. Once daily application unlikely

bath/shower/handwash and in between times to keep

to be enough even if a richer (higher lipid content)

skin supple

emollient were used

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

Uses aqueous cream as leave on emollient this was

Suggest humectant-containing cream (e.g. Eucerin,

almost certainly intended for use as an emollient soap

Aquadrate, Calmurid) for daytime use and Doublebase

substitute. Needs a richer emollient. (Note: has

for the nights

Doublebase but does not use)

Not using an emollient soap substitute for washing

Explain about using emollient soap substitutes and

use of soap will undo benefits of steroid/emollient

emphasise the importance of avoiding soap because

treatment

of its drying effects. Demonstrate use of aqueous

Further reading

cream for washing. Suggest shower/bath product

(see below)

Atopic eczema in primary care. MeReC Bulletin

(July 2003) 2003;14:1
NICE Technology Appraisal Guidance TA81:

No treatment for itching

Suggest a shower product containing polidocanol to

Frequency of application of topical corticosteroids for

combat itching. Recommend cool bedroom. Suggest

atopic eczema. August 2004

Lorna considers using cotton gloves at night to make

How to choose a suitable emollient. Clark C. Pharm

involuntary scratching more difficult

J 2004;273:351-353
Making the most of emollients. Clark CM and Hoare
C. Pharm J 2001;266:227-229

Signpost: To National Eczema Society (NES)

Understanding Eczema. De Berker D. Family Doctor

Publications

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Competences

Where this module supports competence development

C1a, C1b, C1c, C1d, C1f

The module addresses the appropriate and effective use of

pharmacological treatments and non-pharmacological measures
in the management of eczema.
Reflection exercise 1 addresses discussion of the risks and
benefits of treatment

C3c, C3e

The module addresses the way in which the MUR process can be
used to help patients with chronic eczema

which is then covered by a wet cotton tubular

bandage. This bandage is then over-wrapped
with a dry bandage. Apart from the scalp,
the bandages can be applied over the whole
body and can be left in place overnight. Close
supervision is required when a topical
corticosteroid is used, because the occlusion
increases the likelihood of absorption and the
risk of systemic adverse effects.
Behavioural therapy using a variety of
techniques (including hypnotherapy, cognitive
behavioural therapy and autogenic training) has
also been used as an adjunct to conventional
treatment in cases of eczema, often with good
results.

Patient support groups

One of the most helpful things you can do for
people with eczema is to signpost them to the
various patient support groups that offer
support in this area, in particular the National
Eczema Society. In addition to running a
helpline, producing a journal and providing
information, the NES also has local groups that
can provide additional support.

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

REFLECT

PLAN

A
PH

ACT

E VA L U AT E

ODULE
PULL

OUT

AND

KEEP

CPD

RMA

MAGAZ

NE

People whose eczema fails to respond to

emollients, topical steroids and avoidance of
trigger factors are referred to a specialist who
may recommend immunosuppressant treatment (e.g. ciclosporin, azathioprine or phototherapy similar to that used for psoriasis
treatment).
Another approach that is used for extensive,
severe eczema in young children is wetwrapping. A generous layer of emollient or mild
topical steroid cream is applied to the skin,

This module supports the following community pharmacy competences:

Treatments available from specialists

CPD competences

their use is restricted to physicians (including

GPs) with a special interest and experience in
dermatology, and only after careful discussion
with the patient about the potential risks and
benefits of all appropriate second-line treatment
options. Pimecrolimus is used to treat mild to
moderate eczema and tacrolimus to treat
moderate to severe atopic eczema. Both
tacrolimus and pimecrolimus are inhibitors of
calcineurin phosphatase, a key enzyme in the
activation of T-cells and propagation of the
inflammatory response.
Recent guidelines from the National Institute
for Health and Clinical Excellence (NICE)7
suggest that tacrolimus may be used in three
situations:
As an alternative to potent corticosteroids that
would be inappropriate on sensitive areas such
as the face
When otherwise potent corticosteroids would
be needed most of the time
When there is evidence of corticosteroidinduced skin damage.
The main side-effect of both tacrolimus and
pimecrolimus is a burning sensation in the
skin. This effect usually only lasts a few days and
patients are advised to persevere with treatment
in these circumstances.

CPD VII MARCH 2007 PHARMACY MAGAZINE

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ASSESSMENT

QUESTIONS

PHARMACY MAGAZINE CPD RECORD MARCH 2007

USE THIS FORM TO RECORD YOUR LEARNING AND ACTION POINTS FROM THIS MODULE ON
ATOPIC ECZEMA AND INCLUDE IT IN YOUR CPD PORTFOLIO

Activity/development completed
(Act)

ATOPIC ECZEMA
1. Which statement is TRUE
regarding eczema in the UK?
It affects:

6. Which is NOT true of

topical steroids when used
for treating eczema?

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

15-20 per cent of children

15-20 per cent of adults
10-15 per cent of children
10-15 per cent of adults

2. Which of the following is

associated with chronic
eczema?
a. Exudation and crusting
b. Blistering and
inflammation
c. Lichenification and
fissuring
d. Vesicles that burst and
weep

3. Which is NOT found in the

epidermis?
a. Natural moisturising factor
(NMF)
b. Corneodesmosomes
c. Filaggrin
d. Chymotrypsin

4. Which is NOT an effect of

emollient treatment?
a. Trapping of water in the
stratum corneum
b. Preventing bacterial
colonisation
c. Mimicking of the functions
of barrier lipids
d. Restoring suppleness to
the skin

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:

Time taken to complete activity:

What did I learn that was new?

(Evaluate)

7. Which is the most

appropriate strategy for the
treatment of infected
eczema?
a. Long-term topical
antibiotic treatment
b. A short course of topical
antibiotic treatment
c. A short course of systemic
antibiotic treatment
d. A short course of combined
topical and systemic
antibiotic treatment

8. Find the FALSE statement

below. The topical immunomodulator tacrolimus can
be used:
a. As an alternative to a
potent corticosteroid when
there is eczema affecting
the face
b. When there is evidence of
corticosteroid-induced
skin damage
c. When eczema affecting the
trunk and limbs cannot be
managed with a topical
corticosteroid
d. When eczema is associated
with a burning sensation

How have I put this into practice? (Provide examples of how learning has been applied what did you do differently as a result?)
(Evaluate)

Do I need to learn anything else in this area?

(Reflect)

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.

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b.

b.

b.

b.

b.

b.

b.

c.

c.

c.

c.

c.

c.

c.

c.

d.

d.

d.

d.

d.

d.

d.

d.

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137