More than skin deep

9651368 - this is eczema on face of newborn

By educating patients on the importance of a daily skincare regime, assisting with product selection and facilitating effective self care, pharmacy can play an important role in the treatment of many dermatological conditions

There are a multitude of factors that can affect the integrity of our skin; some medications (such as diuretics and cholesterol lowering drugs), certain disease states (diabetes) and simply growing older can impact the structure and condition of the skin.

Dr Esther Hong from St George Dermatology, NSW, explains, “Ageing skin becomes thinner and loses its ability to hold moisture due to loss of dermal collagen and hyaluronic acid. Effects of sun and UV exposure also accumulate over time. Hence elderly skin is more prone to dryness, wrinkling, easy bruising and discoloration.

“Pathological changes, such as eczema and skin cancers, are also more common with increasing age.”

She says in general dry skin should be moisturised daily and treated with adequate care, which means avoiding factors that can exacerbate dryness.

“Over-zealous washing, using harsh soaps and forgetting to moisturise regularly, especially during dry winter weather, can all contribute to dry skin.

“Signs of dry skin include roughness, flaking and dull texture. Severely dry skin can crack and fissure, causing itch and even pain.”

She says pharmacists can advocate the use of gentle, soap-free cleansers and washing with lukewarm, rather than ‘hot’, water.

“Daily use of SPF 50+ sunscreen should be part of the skincare routine to prevent photo-damage and avoid smoking!

“When helping a patient select the right emollient for them, it’s important to understand their lifestyle. Are they very physically active? Do they prefer light or thick moisturisers? Do they suffer with dry skin conditions such as eczema? What is their budget?

“Depending on the dryness of the skin, you might suggest either an oil-based or water-based emollient. Lotions and gels are the lightest moisturisers with the highest water content. Creams are thicker than lotions. Ointments are the most hydrating moisturisers, with the highest concentrations of occlusive oils, such as paraffin or petrolatum.

“It can be useful to explain the different types of formulas and how to best use them. You can also suggest mixing and matching various types of moisturisers for night and day, summer and winter. Lotions are preferable for everyday use especially before heading out to school or work and for use on the hands, whilst heavier creams and ointments may be reserved for use before bed or during the dry winter months.”

She adds, “People with very dry skin conditions, as seen in eczema and ichthyosis, can benefit from regular use of emollient preparations containing urea and acids (such as lactic and salicylic acid), which has the double effect of super-hydration and gentle exfoliation to keep skin supple if used long-term.”

The role of emollients in eczema treatment

“Emollients have been used for over 5,000 years and they form an essential part of the therapy for all dry skin conditions, including atopic and contact eczema,” says Dr Michael Cork, senior lecturer in dermatology and consultant for the National Eczema Society.

“Emollients are safe and effective and, in the majority of cases, mild to moderate eczema can be successfully treated by using emollient therapy alone.

“Unfortunately emollients are under-used, as people often perceive them to be inactive moisturisers and do not understand why they are so important in controlling eczema. When used correctly as a daily skin care regime, emollients become effective ‘active treatments’. Emollient therapy is not just about products but understanding how and when to use them.”

Pharmacists and their staff are in an ideal position to remind patients on how to get the most benefit from their emollients:

  • Emollients are best applied immediately after a bath or shower while the skin is still warm and the pores are open
  • Apply liberally to affected skin
  • On average emollients should be applied 2-3 times a day but can be applied more often if skin is particularly dry
  • Smooth (don’t rub) in the direction of hair growth
  • Different types of emollients can be used interchangeably to suit lifestyle and daily routine
  • Emollients should continue to be applied, even when the skin is not inflamed, as maintenance to prevent flare-ups

Associate professor Chris baker, president of the Australasian College of Dermatologists adds, “Pharmacists be aware; when dry skin reaches a certain point it can become eczema.

“Dry skin is itchy but if it starts to become reddened, inflamed, cracked or weeping, it’s a signal that eczema or dermatitis is developing. When this happens moisturiser alone might not be sufficient, so a topical steroid cream might be required.

“Where weeping and crusting is evident, think about secondary infection. These might be triggers to refer back to the doctor.”

The evidence and advice on corticosteroids

Topical corticosteroids (TCS) have been widely used in inflammatory skin diseases, such as eczema and psoriasis, since the 1950s and yet there is still much discussion on their safety and efficacy.

Saxon Smith, clinical associate professor of dermatology, The Dermatology and Skin Cancer Centre, Gosford, NSW, explains the mechanism of corticosteroids.

“TCS reduce protein synthesis and cellular mitosis as well as inhibiting the proliferation, migration and chemotaxis of fibroblasts. The secretion of certain interleukins is inhibited and the vasoconstrictive effects of adrenaline promoted. TCS also reduce the inflammatory action of histamine and bradykinin.

“The significant knowledge gaps about the use and safety of TCS in paediatric atopic dermatitis amongst Australian pharmacists and their advice to patients potentially contributes to poor treatment concordance.

“However, these attitudes appear modifiable through targeted, evidence-based education delivered by a dermatologist.

“Further analysis of the results of our study demonstrated that pharmacists younger than 40 years of age and those that had been practising less than 10 years were more likely to recommend TCS use for a short duration. Furthermore, only 14 out of 95 that had been practising for less than 10 years (15%) recommended that TCS be used until the eczema was clear.

“A multicentre cross-sectional survey of patients (aged >18) and parents of paediatric patients (aged <18) with a history of long-term (≥ 1 month) TCS use explored the impact and influence of the benefit and risk messages on parents and patients. A total of 201 surveys were completed consisting of 123 adult patients and 78 parents. Most respondents (76.6%) reported that they consistently (‘Often’ or ‘Always’) received one or more message regarding TCS ‘risk’ from a GP and/or pharmacist.

“An Australian consensus guideline on the safety and efficacy of TCS in paediatric eczema was published two years ago; it shows that the rate of these potential side effects occur rarely and usually only in the setting of overuse.  Similar to paracetamol being potentially hazardous if taken incorrectly, if you use TCS for prolonged periods of time on non-diseased skin then you potentially can see these adverse effects.  However, when TCS are used to treat the right skin diseases under direct supervision of their treating doctor, then these side effects are rare.”

Educating on potency, preparation and use

According to the National Eczema Society, the potency of TCS is determined by the amount of vasoconstriction they produce but also takes into consideration the degree to which the topical steroid inhibits inflammation as well as its potential for causing side effects.

Depending on the severity of the eczema and location on the body, patients may be given more than one TCS of varying strengths to be used at different times and on different areas of skin.

Pharmacists play a vital role in supporting optimal treatment outcome by ensuring, or reminding, patients when and where to use the different TCS preparations.

  • Lotion – mild skin dryness and infrequent eczema flare-ups. Light and cooling. Good for use of hairy parts of the body as easier to spread
  • Cream—moderate to severe dryness. Can be used on areas of weeping eczema
  • Ointment—moderate to severe dryness. An ointment doesn’t need to be applied as frequently as a cream but it can be messy to apply. Good for very dry eczema and for use at bedtime.

Smith says, “It’s very important to take into account patient preference.  If you suggest a vehicle or type of formula that a patient does not prefer it has the potential to lead to treatment non-compliance and ultimately poorer control of their skin disease.”

With regards to potential side effects he says, “There is limited evidence that increased potency of TCS leads to increase chances of side effects, especially when used under the direct supervision of their treating doctor.  In fact previously published Australian research demonstrated in the paediatric eczema population there is no evidence of ‘skin thinning/atrophy’ despite prolonged use of TCS to control their condition.

“The fundamental guide to treatment is using a strong enough TCS for long enough.  There are times when dermatologists will use TCS for prolonged periods of time in order to control the specific skin condition.  However in the pharmacy day to day if the skin condition doesn’t improve after up to 14 days then it is important for the patient to see their GP or dermatologist for further assessment and treatment advice.”

While both emollients and TCS are fundamental in the treatment and management of eczema, TCS are often only used during acute flare-ups and then their use is ceased.

The proactive approach involves using mild TCS (alongside emollients) in the day-to-day management of eczema and a high-dose corticosteroid during a flare-up.

The Eczema Association of Australia (EAA) recommends that TCS maintenance therapy should be applied on two consecutive days each week. Hence it is commonly referred to as ‘weekend therapy’ – although you could apply it on a Wednesday and Thursday, for example, rather than the Saturday and Sunday, as long as the days are consecutive.

Smith says that it is knowledge gaps about the use and safety of TCS and advice to patients that potentially contributes to poor treatment concordance.

Healthcare professionals need to be giving consistent messaging and correct advice, based on evidence.

Cheryl Talent, president of the EAA says, ”One of the problems eczema sufferers face on a daily basis is the influx of information and how much of it is relevant to them and how much is correct.

“Pharmacy is often the first port of call before the GP, so it’s really important that pharmacy staff give the right advice.

“The problem we face is that people with eczema are being told to be careful and use their steroid cream sparingly, so people go home and they don’t use it at all. This is the wrong information. Currently steroid creams are the only way to effectively manage an eczema flare up, although steroid cream is not the be all and end all. We should recommend its used in conjunction with natural therapies, daily moisturiser and dietary requirements; it’s part of a total solution.”

The key messages about TCS are:

  • If used appropriately topical corticosteroids are deemed safe and effective
  • Side effects are rare
  • Recommending that topical corticosteroids be used “sparingly” or “applied thinly” adds to problem of steroid phobia
  • Poor clinical response, lack of compliance or treatment failure is in part attributed to the steroid phobia that exists

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