Eczema: An Itchy Nuisance Part 3
By Darrel Arthurs, ARNP, DCNP
Last month, we discussed basic skin care and some of the over the counter treatments available for the eczema patient. In this blog I will discuss more treatments available as well as topical treatments, which can be helpful getting a more severe condition under control.
Wet Wrap Therapy
A patient with a significant flare or a very recalcitrant condition not responding to traditional treatments can be responsive to wet wrap therapy. This therapy is now used on an inpatient basis and the method is taught to the parents to continue therapy at home.
The success rate for wet wraps is extraordinarily high if used correctly. The best technique is to use a topical corticosteroid (TCS) applied to the skin with a moist layer placed over the body area treated. This could be tubular bandages for the extremities or any cotton clothing that can be moistened (footy jammies are actual useful for this application but not normally recommended for the eczema patient).
On top of this a dry layer is placed to decrease the effects of the wetness on furniture and the patient is allowed to sit for 2 to 12 hours. By occluding the TCS it increases the effectiveness as well providing much needed moisture to the skin and a physical barrier against scratching.
TCS are used in both children and adults and are the go-to treatment for moderate to severe eczema. They act by decreasing inflammation and the immune response at the site of application. Normally, they are added to the regimen after good skin care and moisturization regimens fail. TCS's have been in use for over 60 years and their effectiveness is well documented. They are the standard that other topical anti-inflammatories are compared to.
TCS's are grouped into 7 categories from very low (VII) to very high potency (I). Methods that can be used to treat with TCS's include two options. First the provider can start low and move higher until the condition is well controlled. The other method is to use a short burst of high potency TCS to get the condition under control quickly and then to decrease the dose to the desired level of treatment.
While there is no universal method there are other factors involved including length and severity of condition. Normally by the time they reach dermatology the condition is severe. For this reason I normally start high and drop the potency once the symptoms improve.
Everyone wants a recipe to treat all of the eczema that walks through the door and unfortunately, there isn't one but I will give a brief, very basic synopsis of a treatment plan with actual generic TCS names.
For young children and pre-teens use triamcinolone (TMC)0.1% and then decrease to hydrocortisone 2.5% or a TMC 0.25%. For teens and adults with medium and severe disease start with clobetasol 0.05% then drop to TMC 0.1%. Ointments are preferred if possible and are more effective than creams. In addition, they normally do not burn and sting when used on excoriated skin. Always use only mild TCS for the face and groin areas and for short periods of time.
This blog is not meant to be a comprehensive treatment plan. My hope was to spark an interest in the subject with the reader and elicit more research. I am adding a great journal article reference to this blog and, in addition, education can be found at the NADNP website, http://www.nadnp.net/.
Starting this year traveling dermatology continuing medical education will available at different locations across the country to allow you, the reader, an opportunity to further your knowledge of this fascinating subject.
- Eichenfield FL, et al. Guidelines for the management of atopic dermatitis. J Am Acad Dermatol. 2014;70(2):338-351. doi: 10.1016/j.jaad.2013.10.010
- National Academy of Dermatology Nurse Practitioners. http://www.nadnp.net/
Arthurs' passion for dermatology developed while he was serving in active duty in the U.S. Navy. Since then he has accumulated over 11 years' experience in medical and surgical dermatology. Currently he works independently in a small city in northeastern Oklahoma. Arthurs is on the NADNP Board of Directors.