Many patients accept their skin condition with equanimity but others suffer much distress, especially if the face and hands are affected.
Acceptance by the doctor of the individual and his or her attitudes to the disease goes a long way to helping the patient live with the condition.
The common inflammatory skin diseases can nearly always be improved or cleared, but it is wise not to promise a permanent cure.
Be realistic about the treatment people can apply in their own homes.
It is easy to unthinkingly give patients with a widespread rash a large amount of ointment to apply twice daily, which is hardly used because:
(a) they have a busy job or young children and simply do not have time to apply ointment to the whole skin;
(b) they have arthritic or other limitations of movement and can reach only a small part of the body;
(c) the tar or other ointment is smelly or discolours their clothes. Most of us have been guilty of forgetting these factors at one time or another.
Dry skin tends to be itchy, so advise minimal use of soap.
Emollients are used to soften the skin, and the simpler the better.
Emulsifying ointment BP is cheap and effective but rather thick.
By mixing two tablespoons in a kitchen blender with a pint of water, the result is a creamy mixture that can easily be used in the bath.
A useful preparation is equal parts of white soft paraffin and liquid paraffin. Various proprietary bath oils are available and can be applied directly to wet skin.
There are many proprietary emollients. Wet weeping lesions should generally be treated with creams rather than ointments (which remain on the surface). Steroid ointments are effective in relieving inflammation and itching but are not always used effectively.
Advise patients to use a strong steroid (such as betamethasone or fluocinolone acetonide) frequently for a few days to bring the condition under control; then change to a weaker steroid (dilute betamethasone, fluocinolone, clobetasone, hydrocortisone) less frequently.
Strong steroids should not be continued for long periods, and, as a rule, do not prescribe any steroid stronger than hydrocortisone for the face.
Strong steroids can cause atrophy of the skin if used for long periods, particularly when applied under occlusive dressings.
On the face they may lead to florid telangiectasia and acne-like pustules. Avoid using steroids on ulcerated areas.
Prolonged use of topical steroids may mask an underlying bacterial or fungal infection.
Immunosuppressants are a valuable adjunct in severe cases not responding to topical treatment and antibiotics.
Ciclosporin is usually given on an intermittent basis, with careful monitoring for side effects.
Azathioprine is also used, provided the thiopurine methyl transferase (TPMT) level is normal.
Tacrolimus is an immunosuppressant that has recently become available in two strengths as an ointment.
It promises to be a successful treatment but is relatively expensive. Specific treatment
Wet, inflamed, exuding lesions
(1) Use wet soaks with plain water, normal saline, or aluminium acetate (0·6%).
Potassium permanganate (0·1%) solution should be used if there is any sign of infection.
(2) Use wet compresses rather than dry dressings (“wet wraps”).
(3) Steroid creams should be used as outlined above. Greasy ointment bases tend to float off on the exudate.
(4) A combined steroid–antibiotic cream is often needed as infection readily develops.
(5) Systemic antibiotics may be required in severe cases. Take swabs for bacteriological examination first.
Dry, scaling, lichenified lesions
(1) Use emollients.
(2) Use steroid ointments, with antibiotics if infection is present.
(3) A weak coal tar preparation or ichthammol can be used on top of the ointments. This is particularly useful at night to prevent itching.
1–2% coal tar can be prescribed in an ointment.
For hard, lichenified skin salicylic acid can be incorporated and the following formulation has been found useful in our department:
(a) Coal tar solution BP 10%, salicylic acid 2%, and unguentum drench to 100%.
(b) 1% ichthammol and 15% zinc oxide in white soft paraffin is less likely to irritate than tar and is suitable for children.
(4) In treating psoriasis start with a weaker tar preparation and progress to a stronger one.
(5) For thick, hyperkeratotic lesions, particularly in the scalp, salicylic acid is useful.
It can be prescribed as 2–5% in aqueous cream, 1–2% in arachis oil, or 6% gel.
It is often easiest for the patient to apply the preparation to the scalp at night and wash it out the next morning with a tar shampoo.
Infection
Remember that secondary infection may be a cause of persisting lesions.
Hand dermatitis
Hand dermatitis poses a particular problem in management and it is important that protection is continued after the initial rash has healed because it takes some time for the skin to recover its barrier function.
Ointments or creams should be reapplied each time the hands have been washed.
It is useful to give patients a list of simple instructions such as those shown in the box on the right.
