BRrrISH MEDICAL 8 DECEMBER 1973 605 BRITISH MEDICAL JOURNAL 8 DECEMBER 1973 605 Today's Treatment Br Med J: first published as 10.1136/bmj.4.5892.605 on 8 December 1973. Downloaded from Diseases of the Skin Management of Eczema-II H. BAKER British Medical journal, 1973, 4, 605-607 Standard Strength Compounds Several standard strength compounds are available and (not- withstanding various claims to the contrary) the following are of roughly equal clinical effectiveness in eczema, in the concentra- Steroids in Eczema tions at which they are presented: 0.1 % triamcinolone acetonide (Adcortyl); 0.025% fluocinolone acetonide (Synalar); 0.1% Judicious use of topical corticosteroids for their non-specific betamethasone valerate (Betnovate); and 0.025% beclomethasone anti-inflammatory effect is central to the management of eczema, dipropionate (Propaderm). whatever its cause. Their effect is suppressive and if the cause of The prescriber will make his own choice (as will often the the eczema continues to operate over an indefinite period, patient), perhaps partly influenced by the considerable variations topical therapy will have to be prolonged, bringing in its wake in price, but more by the patients' tolerance of the base of the the now well-known hazards of such treatment. chosen preparation. The prescriber must choose his steroid and also the appropri- Two more recent products are claimed to have particularly ate vehicle (ointment, cream, gel, or lotion). He should be virtuous bases (Metosyn and Topilar) but in my view they have guided by the intensity of the inflammation, its likely duration, not added a significant new dimension to therapy. and its site in choosing the steroid-and by the physical nature of the eczematous surface in selecting the vehicle. These points were discussed in detail by Dr. J. H. Hunter in the second article High-potency Compounds in this series (British Medical Journal, 17 November, p. 411) These are Propaderm Forte (0.5%); Synalar Forte (0.2%). Both of these preparations are presented in 5-g tubes, and are intended http://www.bmj.com/ CHOICE OF CORTICOSTEROID to be reserved for particularly resistant and localized conditions. They are occasionally of value in small but intractable areas of It is convenient to think in terms of four potency levels of the nummular eczema. available preparations. In ascending order of strength these are It is not yet clear where the new preparation clobetasol as follows: propionate, 0.05% (Dermovate) should be placed. In terms of potency, it should probably be placed with the last category, but, in offering it in 25-g and 100-g tubes, the manufacturers would it to be of Hydrocortisone clearly prefer top the second (standard) division. At on 30 September 2021 by guest. Protected copyright. present, it is probably best reserved for the most stubborn Hydrocortisone, 1% or even 0.5%, is the weakest, but may be eczemas (as the manufacturer indicates) and, unless diluted, quite adequate and effective in low-grade eczema. Its chief should not lightly be re-prescribed over long periods. virtue is that it does not induce the serious local effects seen with its halogenated derivatives. It is appropriate, for instance, for chronic atopic eczema, pityriasis alba, or any facial eczema. REMOVAL OF HYPERKERATOSIS Especially on the palms, eczema may be appreciably hyperkera- Low-potency Halogenated Corticosteroids totic. Control of the inflammation by topical corticosteroids may itself reduce epidermal thickening, especially if it is combined These are of low potency either because of the compounds with occlusion. Zinc and salicylic acid paste B.P. (Lassar's paste) chosen-example, Ultradil-or because of the concentration may be helpful, but higher concentrations of salicylic acid may employed-example, Synandone, or Haelan. Many patients can be required; up to 6% can be incorporated in emulsifying be safely helped over long periods by these preparations, some ointment B.P. of which can be sensibly and economically prescribed in large tubes (50g or 60g). CHOICE OF BASE (VEHICLE) Most of the products mentioned are available as lotions, creams, and ointments. In brief, ointments are inappropriate on wet, exudative eczematous surfaces-as are lotions on dry, lichenified ones. Except on the scalp (where gels are useful), a lotion is rarely The London Hospital, London needed for more than two to three H. BAKER, M.D., F.R.C.P., Consultant Dermatologist days, being then replaced by a cream or ointment. Creams are often more acceptable to the 606 BRITISH MEDICAL JOURNAL 8 DECEMBER 1973 patient in the domestic or working environment, but ointments patient if the doctor prescribes him woefully inadequate are often more effective. Notwithstanding pharmacological amounts. Conversely his prescribing should not be wasteful. If theory, in practice trial and error often determine the best large areas of skin require treatment twice daily, well-diluted Br Med J: first published as 10.1136/bmj.4.5892.605 on 8 December 1973. Downloaded from preparation. These aspects were discussed in Dr. J. Hunter's preparations should be used (see above), but the amount must second article in the series. be adequate (example, steroid ointment 60g, soft white paraffin to 250g). Nevertheless, undiluted standard steroids are seldom needed in amounts larger than 30g. DILUTION OF CORTICOSTEROID PREPARATIONS Creams should not often be diluted as their stability, sterility, and ability to release the active agent may all be compromised. Systemic Drugs in Eczema Topilar cream may be diluted if the manufacturer's special base provided for this purpose is used (F.A.P.G. diluent). Antibiotics, antihistamines, psychotropic drugs, and cortico- The standard strength corticosteroid ointments (except steroids all have a place in some patients. Metosyn) may be safely diluted with soft white paraffin B.P. One-in-four or one-in-five dilutions allow adequate amounts of an effective ointment to be economically supplied, but the dilution can be reduced or even increased (example, to one-in- ANTIBIOTICS ten) as appropriate. The clinician should be guided by the principle of using the lowest strength of steroid adequate for its The routine systemic use of antibiotics in any form of eczema purpose. is unnecessary, wasteful, and sometimes harmful. Secondary infection may be present, caused by Staphylococcus aureus or Streptococcus pyogenes. The need for an antibiotic is clear only INTRALESIONAL THERAPY in the following instances: (1) When localized eczema is complicated by lymphangitis or cellulitis Direct injection of a steroid into a recalcitrant plaque of eczema and tender regional lymphadenopathy. may be useful if this manoeuvre is not overused. Adcortyl Such infection may be assumed to be streptococcal and is usually suspension (10 mg/ml) is usually given either by intradermal seen with acute pompholyx eczema of the hands or an acute or chronic needle or (in the clinic) by Dermojet gun. The action may last eczema of the feet. Less often it originates in hypostatic eczema for many weeks owing to the depot effect produced by the associated with a gravitational ulcer. Potassium penicillin V is the drug highly water-insoluble steroid in situ. It is not usual to employ of choice since S. pyogenes is always sensitive to it. If the patient is these techniques unless topical therapy has failed. known to be allergic to penicillin, erthromycin is the best alternative. In patients with recurring attacks of streptococcal cellulitis- associated, for instance, with a chronic endogenous eczema of the foot-long-term maintenance penicillin (potassium penicillin V, PLACE OF POLYETHYLENE OCCLUSION 250 mg, twice daily) may be indicated to prevent progressive lymphatic damage, increasing oedema, and reciprocal aggravation of the eczema After steroid preparations have been applied to the skin, itself. covering it with any material impermeable to water vapour Failure of acute lymphangitis to respond to adequate doses of (example, polyethylene) will enhance the penetration of the penicillin may be puzzling and is generally attributable to mixed infection of the primary eczema with a penicillin-resistant Staph. http://www.bmj.com/ steroid through the epidermis by hydrating the stratum corneum aureus, whose penicillinase is gratuitously protecting the streptococcus: and thus reducing the latter's barrier efficiency. Polyethylene switching to flucloxacillin produces rapid resolution. gloves may be used for the hands and bags for the feet. This procedure potentiates the effects of the steroids, but the other (2) When an eczema is complicated by painful folliculitis and effects of such hydration should be not forgotten. Firstly, the "boils," which are making the patient "toxic." Such staphylo- proliferation of the surface bacteria is promoted-so that if coccal infection may sometimes be directly attributable to pathogenic staphylococci are present in the occluded area serious topical steroid therapy. pyoderma may result. Secondly, enhancing the potency of the (3) In infected seborrhoeic eczema which is resistant to on 30 September 2021 by guest. Protected copyright. steroids implies a risk of correspondingly magnified side effects. topical therapy. Nevertheless, nocturnal occlusion may be very useful in non- (4) In acute infective "dermatitis" of the feet in older boys, infected intractable eczemas of the hands and feet, especially usually seen about the toe clefts and dorsa of the feet near the of the hyperkeratotic variety. bases of the great toes. In all the above instances the sooner bacteriological culture and antibiotic sensitivity data are available the better-though TOPICAL STEROID-ANTIBIOTIC COMBINATIONS the doctor should not wait for these before he starts treatment. Apart from the instances just described, the role of micro- A "blunderbuss" approach to the topical treatment of eczema organisms in eczema is controversial and here bacteriological is rarely needed or rational. Infective retroauricular eczema in information may only mislead. children (usually atopic), and the infective eczema not un- commonly seen about the toes in older boys-and more rarely on the hands in adults-are clear indications for steroid- antibiotic combinations.