Facts

John Bell saysBehind the Fact Card Atopic eczema and xerosis Pharmacist CPD Module number 260

Atopic eczema and xerosis

By Jill Malek This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed.

Atopic eczema is a chronic,

itchy skin condition that is
commonly called ‘eczema’. It is
also known as atopic dermatitis or
neurodermatitis.1 Atopic eczema
is very common in children,
but can occur at any age.1
It accounts for about 60% of all
inflammatory skin conditions.2

Xerosis (dry skin) is a known

trigger for flares of atopic
eczema, especially if it is left
untreated.3 Regular moisturising
and avoiding the use of soap
are simple management
techniques for treating dry skin.3
Application of a steroid cream or
ointment may also be needed if
the eczema flares up.4 Jessica, 17 years old, has been using more likely than normal skin to become
hydrocortisone cream for the last 7 days, red and inflamed on contact with
substances that can irritate skin or cause an
to treat an atopic eczema flare. The flare
allergic reaction.7
has now resolved and she has ceased
use of the corticosteroid. She comes to Atopic eczema has also been linked to a lack
of the skin protein called filaggrin. Lack of
the pharmacy asking for some advice
filaggrin may explain why, in some people,
about how to prevent another flare as eczema continues into adult life rather
she doesn’t like to use ‘steroid’ creams all than ceasing in childhood (85% of children
the time. grow out of atopic eczema before 5 years
of age8).9

Causes and triggers Atopic eczema flares appear to be

linked to external and internal triggers.10
External triggers include substances that
Atopic eczema cause skin irritation (e.g. detergents,
shampoos, soaps, or other chemicals).10
Learning objectives There is no single known cause of atopic
Atopic eczema can also be triggered by an
eczema, but a number of genetic and
After reading this article, pharmacists environmental factors are thought to allergic reaction in response to house dust
should be able to: be involved.5 mites, moulds, grasses, plant pollens, foods,
pets, clothing, soaps, shampoos, washing
t
Recognise the link between eczema A breakdown in the barrier function of powders or other chemicals10 (see Table 2).
and xerosis the skin and abnormal T-cell function
are thought to be important in the Internal triggers such as (a) family history of
t
Advise on treatment of acute eczema, asthma or hay fever (the strongest
eczema flares development of atopic eczema.6
The breakdown in barrier function leads to predictor) and (b) response to certain foods
t
Counsel patients on strategies to increased evaporation of water through the (e.g. dairy and wheat products, citrus fruits,
reduce eczema and xerosis. skin’s epidermal layer (transepidermal water eggs, nuts, seafood, alcohol), chemical food
loss), an increase in skin pH and decreased additives, preservatives and colourings,
Competencies addressed: 1.3, 6.1, and (c) stress have all been linked to the
6.2, 6.3. natural moisturising ability. These factors
lead to inflammation, greater infection development of atopic eczema.10
risk and dryness.2 Eczematous skin is

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Atopic eczema and xerosis Pharmacist CPD Module number 260 Facts Behind the Fact Card

Table 1. Presentation of atopic eczema based on levels of severity*

Severity Presentation
Practice point 1
Clear Normal skin, no evidence of active atopic eczema
Applying emollients
Mild Areas of dry skin, infrequent itching (with or without small areas of redness)
Moderate Areas of dry skin, frequent itching, redness (with or without excoriation and localised skin
When applying emollients2,13,14:
thickening) t
wash hands before applying to reduce
Severe Widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive the chance of cross-infection
skin thickening, bleeding, oozing, cracking and change to skin pigment) t
keep nails short, smooth and clean to
* Adapted from SIGN Management of atopic eczema in primary care guidelines help prevent any trauma to the skin
t
apply liberally and frequently,
Xerosis Presentation every four hours or at least two to four
times a day (recommended quantities
Xerosis (also known as dry skin) affects The presentation of eczema will depend used in generalised eczema is
people of all ages (including up to 75% of on the type of eczema and the level of 500 g/week for an adult and
people over the age of 64 years) and is severity (see Tables 1 and 2).2,13 In atopic 250 g/week for a child)
commonly seen in people with atopic eczema, the skin may appear red, blistered,
eczema.3,4 Xerosis is also a contributing t
use during and after bathing to
oozing, crusted, scaly or thickened, help retain the moisture in the skin;
factor to the worsening of atopic and sometimes the colour will change.
eczema symptoms.4 use when washing skin (e.g. soap
Chronic eczema lesions may become substitute), then dry the skin gently,
Xerosis can develop from a mild condition thickened (lichenification) with repeated leaving it slightly moist before
to a condition that persists and worsens. scratching.2,13,14 In acute flares, applying the leave-on emollient
When the epidermis loses moisture, the presentation may vary from fluid-filled (e.g. cream, ointment, oil) (see Table 3)
fine cracks appear (eczema craquele) vesicles to areas of overall redness.14
t
apply regularly even if there are no
in the skin. These cracks, if left untreated, Atopic eczema in children (up to active symptoms, as regular use can
can form deep fissures and bleed.4 Dry skin 12 months) is usually first seen on the improve symptoms and reduce the
also causes pruritus, which may be severe extensor surfaces of the limbs, the face, need for TCS use
and lead to scratching. Scratching can the trunk, and the neck.11 As the child
cause excoriation and lead to infection of t
apply smoothly in the general
ages, atopic eczema is more commonly direction of hair growth to prevent
the skin.4 seen on the flexure surfaces of the limbs, build up at hair bases (may lead to
Conditions that increase the risk of dry skin for example the antecubital fossa (cavity of folliculitis), particularly when greasy
include increasing age, zinc deficiency, the elbow) and the popliteal fossa (back of ointments are used
diabetic neuropathy, end-stage renal the knee).11,14 The nappy area is usually
t
smooth gently onto the skin; do not
disease, hypothyroidism, neurological not involved.14
rub vigorously as rubbing will
disorders that decrease sweating and In adults, atopic eczema is often seen as stimulate circulation, generate heat
Sjögrens syndrome. Some medicines, generalised dryness and itching. In those and make the skin feel itchier
such as diuretics and anti-androgens, who have had eczema for a long time,
also increase the risk of dry skin. t
use pump dispensers to prevent
it is often localised to the flexures of the microbial contamination of the
Topical medicines that contain alcohol can limbs.14 Adults may also develop chronic
dry the skin and should be avoided.4 emollient (if the emollient is in a pot,
hand eczema, which may be exacerbated use a clean spoon or spatula rather
Dry skin is often worse during winter due by frequent contact with water, friction than dipping fingers into the pot,
to low humidity.4,11 The skin is also dried or chemicals.11 and avoid sharing pots of emollients
by air conditioning, electric blankets, Atopic eczema increases the risk of skin with other people).
heaters and sunlight. Soaps and infections. Infective organisms on the
surfactants are known to dry the skin by skin such as bacteria (Staphylococci and
decreasing surface skin oils and adversely Streptococci) and yeasts (Malassezia and
affecting the skin’s proteins. Their use Candida) constantly stimulate the immune
should be restricted to the armpit, system resulting in chronic inflammation.15
groin, and face. Bathing, showering or Secondary infections are a complication
swimming for a long period of time, of atopic eczema. Infective organisms can
especially in strongly-chlorinated hot trigger a flare of atopic eczema and change
or cold water, also contributes to skin the presentation of the rash. Bacterial skin
dryness. Brief showers in cooler water infections, usually caused by Staphlyococcus
are recommended.4,11–13 aureus, cause crusting, weeping, increased
itch, pustules and/or surrounding cellulitis
with erythema of otherwise normal-looking
skin. They also cause a sudden worsening of
atopic eczema.14,15

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 Facts
John Bell saysBehind the Fact Card Atopic eczema and xerosis Pharmacist CPD Module number 260

Table 2. Causes and presentations of different types of eczema*

Practice point 2 Endogenous Cause Clinical presentation
Atopic No single cause known. A number of genetic Common in children
Using topical corticosteriods and environmental factors thought to Acute flares appear inflamed, red, sometimes
be involved blistered and weepy patches. In between flares,
Using topical corticosteroids: Usually a family history of atopic eczema, the skin may appear normal or suffer from chronic
t
Apply to well-moisturised skin to hay fever or asthma eczema with dry, thickened and itchy areas

increase the efficacy of the TCS and Scaly skin is commonly seen on the lower legs
especially in the elderly
provide a steroid-sparing effect.
Allow the emollient to be absorbed Nummular Cause unclear – may be triggered initially by Scattered round or oval, blistered or dry skin
(discoid) an injury to the skin, dry skin, irritants, as well patches persist for a few months
before applying TCS.2 as previous experience of atopic eczema
t
Use a cream for acute weeping areas, Seborrhoeic May be due to Malassezia yeasts that live on Scalp becomes inflamed; the eczema often spreads
an ointment if the area is dry or the scalp, face and sometimes elsewhere onto the face and neck, and behind the ears.
thickened, and a lotion on areas that The upper trunk may also be affected

have hair.19 Area looks red and sheds small white flakes of skin

t
Apply enough cream or ointment Gravitational Occurs on the lower legs due to swelling Most common in the elderly
(varicose, venous secondary to poorly functioning leg veins Red, itchy spots, dryness and flaking
to cover the area to be treated,
or stasis)
as undertreatment may not resolve an Skin may change colour and become weepy with
some skin crusting
eczema flare.2
Skin may crack if over-dry, or break down if
t
Estimate the size of the area to be scratched or picked
treated using a flat adult hand and Skin on the lower leg is fragile
measure the correct amount using ‘Champagne bottle’ shape of lower leg
fingertip units (see Practice point 3).24
Eczema craquele Mainly due to water loss from skin (dry skin) Most common in the elderly
t
Ensure the potency is appropriate (xerotic, asteatotic) Linked to a decrease in the oils on the skin Skin has a ‘crazy-paving’ appearance
for the site of application (i.e. mild surface, low humidity, over cleansing of Most common site is the shins
the skin, hot baths, scrubbing the skin and
TCS should be applied to the face, Fissures or grooves can appear which look pink or
vigorous towel drying
genitals and skin folds; application to red, but tend to only affect the superficial layers
Pre-existing dryness and roughness of the of the skin
the palms and soles may require more skin are also linked to this type of eczema
potent TCS) (see Table 4).2 Can be sore and itchy

t
Continue to use until the flare Pompholyx Cause is not known. It is thought factors such Most common in people under 40 years of age
has gone, then cease (this may be (dyshidrotic)
as stress, sensitivity to metal compounds Usually only occurs on hands and feet
7–14 days or less in mild cases, (e.g. nickel, cobalt or chromate), heat and
sweating can aggravate this condition Intensely itchy watery blisters, mostly affecting the
and longer in severe cases or areas of sides of the fingers, the palms of the hands and the
Fifty per cent of people with pompholyx
skin that are thickened).19 have atopic eczema as well, or a family
soles of feet

t
After the flare has resolved, continue history of atopic eczema

to use an emollient every day to Lichen simplex Repeated rubbing or scratching, which may Usually occurs on the outer forearms, but also on
prevent another flare-up.17 be secondary to another skin condition the neck, arms, groin or ankles
(neurodermatitis)
Early changes are redness and swelling with
t
If the flare does not resolve in the exaggeration of the normal skin creases
expected time frame, seek further Thickening, hyperkeratosis and pigmentation
medical review. follow, leading to thick plaques

Exogenous Cause Clinical presentation

Irritant contact Skin damage due to handling irritants Commonly occurs on hands and face, usually at
(e.g. detergents, chemicals), over-exposure to site of contact with irritant
water, cold or friction Can range from mild dryness and skin redness to
More likely in those who have a tendency to burn-like symptoms
atopic dermatitis Can be itchy, painful, red, fluid-filled and ulcerated

Allergic contact An allergy reaction to a specific chemical Frequently seen on the hands
(e.g. nickel, perfume, rubber, hair dye, Skin can be dry, red, cracked, swollen blistered,
preservatives or plants) which develops over weeping, intensely itchy, painful and stinging
a period of months or years
Severity will depend upon the allergen and the
May need to identify the responsible agent length of time it is in contact with the skin
by patch testing

Photosensitivity Thought to occur when photosensitising Seen on sun-exposed sites, e.g. face (except deep
(photocontact) agent in or on the skin reacts to normally creases, under the chin, behind the ears), back of
tolerated doses of ultraviolet or visible light the hand and the ‘V’ of the neck
Eruption can eventually extend, particularly with
photo-allergic eruptions, to involve sun-protected
area
Appearance depends on the photosensitising
agent. It can look like sunburn or a dermatitis

*Adapted from DermNet NZ, eTherapeutic Guidelines7

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Atopic eczema and xerosis Pharmacist CPD Module number 260 Facts Behind the Fact Card

Depending on the severity of the eczema, Emollients

children may experience sleep disturbances.
Emollients are an essential part of treating Practice point 3
Lack of sleep may cause irritability and
behavioural changes. Eczema can also atopic eczema.13 Emollients prevent the
impact on the child’s emotional and movement of water out of the skin by Fingertip units
social development which can lead to placing a barrier (usually a lipid) between
the skin and the environment. This acts to Under- and over-use of topical
psychological problems.2,6 corticosteroids frequently occurs.
soften the skin.18 Ingredients in emollients
include mineral oils (e.g. liquid paraffin, Consumers may be unsure how much
Management petrolatum), waxes (e.g. lanolin, beeswax, cream or ointment to apply. Using a
carnauba), long-chain esters, fatty acids, standard dosing measure, such as the
While there is no known cure, the fingertip unit, may help to overcome
and mono-, di-, and tri-glycerides.4
management of atopic eczema aims to this problem.
Emollients are available in a range of
repair the skin barrier, and minimise and
formulations (see Tables 3 and 4). A fingertip unit (FTU) is defined as the
prevent flares with the use of moisturisers
and by avoiding irritants.9 The principles Emollients are often called moisturisers. amount of cream or ointment, squeezed
of management are generally the same Moisturiser can also mean a product that out of a tube (with a standard 5 mm
for both atopic eczema and all other types combines an emollient with a humectant. nozzle), from the tip of an adult’s index
of eczema.16,17 Humectants have a hygroscopic effect, finger to the first crease.24 One FTU
which increases the hydration and elasticity (approximately 500 mg) is usually
of the skin. Examples of humectant agents enough to cover an area twice the size
include alpha-hydroxy acids such as lactic of a flat adult hand (with the fingers
acid, glycolic acid and tartaric acid, as well together). The same measure can be
used when applying TCS to children.16,24
Table 3. Type and description of emollients*
Pharmacists should demonstrate this
Type Description process by measuring the size of the
area to be treated using their hand. If it
Creams, ointments Creams, ointments and lotions are designed to be left on the skin
and lotions is the size of four adult hands, then two
Creams soak into the skin faster than ointments
fingertip units of cream or ointment
Creams and lotions are usually best to treat moist or weeping areas of skin should be applied each time.24
Ointments are usually best to treat areas of skin that are dry or thickened
For a patient information leaflet, go to
Lotions may be applied to hairy areas, but are often not moisturising enough for atopic
skin and may sting www.amh.net.au/resources/public/
fingertipunits.pdf
Soap substitutes Contain emollient ingredients with very mild emulsifiers
including shampoos Use instead of soap and other detergents
and gels
May be applied to hairy areas, but are often not moisturising enough for atopic skin and
may sting
Bath oils Contain oils and emulsifiers that disperse the oils in the water
Have a cleansing effect if gently rubbed over the skin
Non-dispersing Contain oils with no emulsifying agent
emollient bath oils Oil forms a layer on the surface of the water which is deposited on the skin on getting
out of the bath

*Adapted from SIGN Management of atopic eczema in primary care guideline, eTherapeutic Guidelines19

Table 4. Examples of common emollients*

Emollient Characteristics
Aqueous cream Medium greasiness
Sorbolene cream with glycerol 10% Medium greasiness
May cause stinging
Wool alcohols ointment Greasy and sticky
Useful in xerosis
Emulsifying ointment Greasy
Related Fact Cards
Vary formulation by adding water Eczema and dermatitis
May cause stinging Nappy rash
White soft paraffin Very greasy Tinea
Rarely stings
Acne
Vary formulation with aqueous cream or liquid paraffin
Relaxation techniques
*Adapted from PSA Wound care in practice

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John Bell saysBehind the Fact Card Atopic eczema and xerosis Pharmacist CPD Module number 260

as urea, glycerin, and propylene glycol. Topical corticosteroids

Practice point 4 – Other Examples of moisturisers containing
Corticosteroids, used in conjunction with
emollients and humectants include Eucerin,
therapies Cetaphil, Aveeno, QV and Neutrogena
emollients, are the mainstay of treatment
for atopic eczema. Emollients hydrate the
Sedating antihistamines – may be used products.4 See Table 4.
skin. Corticosteroids reduce inflammation
to aid sleep in acute exacerbations of Emollients should be applied two to and are used to manage eczema flares.16
inflammatory skin conditions when four times daily even when eczema is
itching is keeping the patient awake. Topical corticosteroid (TCS) preparations
well-controlled. It is especially important are divided into classes by potency
An appropriate sedating antihistamine to apply emollients after bathing. (see Table 5). Potency can be enhanced
may be recommended for children over Liberal application is required.13,18,19 Refer to by occluding areas of thickened skin
the age of 2 years for the management of Practice point 1. using polythene films (e.g. plastic
eczema.25 Less sedating antihistamines wrap, specialised dressings), as well as
do not usually reduce itching.11 Emollients replace the natural surface oils,
by including absorption-enhancing
and help to13,14:
Topical calcineurin inhibitors ingredients (e.g. propylene glycol) in the
(e.g. pimecrolimus 1% cream) – similar t
soften the skin preparation.16 Formulation is also an
in action to mild TCS, and used for t
restore the impaired barrier function of important consideration. Ointments are
the epidermis generally considered more potent than
maintenance therapy and treating
creams or lotions, as they occlude the skin
early flares of mild-to-moderate t
reduce the itch of dry skin and enhance hydration and absorption.16,22
atopic eczema. It can be applied to
t
increase the efficacy of topical
face, eyelids and other sensitive areas. Choice of potency and formulation is based
corticosteroids (TCS)
Sunscreen should be used on areas on disease severity (see Table 1), area and
of exposed treated skin. Long-term t
reduce the amount of TCS that needs to location, and the patient’s age.16 TCS
continuous use should be avoided.11 be applied. treatment should be stepped up or down
to the lowest potency TCS that is effective2
Phototherapy (e.g. UV light) – may (see Table 5).
be used to treat severe disease that
is unresponsive to other treatment. Table 5. Topical corticosteroid potency comparison and indications*
There are some concerns about the
long-term risk of skin cancer with its use, Corticosteroid Potency Dosage form(s) Indication
particularly in people with white skin.2,11 Hydrocortisone (0.5–1%) Mild Cream, ointment Facial and flexural eczema

Complementary therapies (e.g. zinc, Hydrocortisone acetate Mild Cream, ointment Apply twice daily
vitamin E, fish oil, omega-3, (0.5–1%)
omega-6 fatty acids, probiotics) – have Betamethasone valerate Moderate Cream, ointment Mild-to-moderate atopic
not been found to be beneficial in atopic (0.02%, 0.05%) eczema
eczema.2 Use caution with Chinese Clobetasone butyrate Moderate Cream Apply twice daily
medicines and herbs due to a lack of (0.05%) Lotion formulation used
evidence; liver toxicity has been reported Desonide (0.05%) Moderate Lotion for treating extensive
with some Chinese herbal medications areas as well as hairy areas
Triamcinolone (0.02%) Moderate Cream, ointment
used for atopic eczema.2
Betamethasone Potent Cream, ointment, lotion Short-term use in severe
dipropionate (0.05%) inflammatory dermatoses
Betamethasone valerate Potent Cream, ointment, lotion Apply twice daily except
(0.1%) for mometasone and
methylprednisolone,
Mometasone (0.1%) Potent Cream, ointment, gel, which are usually applied
lotion once a day
Methylprednisolone Potent Cream, ointment, lotion Methylprednisolone may
(0.1%) be used on the face and
flexures if no response
after treatment with
hydrocortisone. Use for
2–3 days (maximum
7 days). Observe closely
Betamethasone Very potent Cream, ointment Severe eczema of hands
dipropionate in an and feet (occlusion may
optimised vehicle (OV) be used but atrophy may
(0.05%) occur)
Apply once or twice daily
Clobetasol propionate Very potent Shampoo Moderate –to-severe-
(0.05%) scalp psoriasis
Apply once daily

*Adapted from AMH online 2015, APF23

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Atopic eczema and xerosis Pharmacist CPD Module number 260 Facts Behind the Fact Card

Absorption of TCS is greatest from the face, Use wet dressings with a TCS in t
applying a topical antibiotic
genitals, flexures and skin folds.19,21 A mild moderate-to-severe atopic eczema, (e.g. mupirocin 2%) ointment or cream to
TCS (e.g. hydrocortisone) should be used especially if the above measures are any crusted areas, twice daily for 7 days
on these areas.11,16 Where the skin is thicker, not working. There should be a good t
taking oral antibiotics for widespread
such as on palms of the hands and soles of response within the suggested time secondary bacterial infection, or if
the feet, a more potent TCS may be required frames. If not, consider using a more potent the eczema has not settled with other
to achieve adequate penetration.16,19,21 corticosteroid, more frequent application, measures and infection is suspected:
Absorption can be further enhanced occlusion, or review diagnosis. Severe
with the use of occlusive dressings or dermatitis not responding to topical - di-/flu-cloxacillin 500 mg (child:
TCS prepared in an occlusive vehicle.16 corticosteroids needs a full assessment by a 12.5 mg/kg up to 500 mg) orally,
In children, hydrocortisone is usually an dermatologist.17 See Practice points 2 and 3. 6-hourly for 10 days
adequate initial treatment. If a more potent - cephalexin 1 g (child: 25 mg/kg up to
TCS is needed, it should be used for the Acute treatment 1 g) orally, 12-hourly for 10 days for
shortest possible time.11 patients with penicillin hypersensitivity
When eczema flares, acute treatment or in children (due to better tolerability,
TCS are both under- and over-used, and is required to reduce inflammation and and more palatable liquid formulation)
pharmacists should advise on the amount pruritus. Skin infection may also be present
of TCS applied. Overuse may lead to skin - roxithromycin 300 mg orally, once daily
and need treatment. Treatment of eczema (child: 4 mg/kg up to 150 mg orally,
damage at the application site and excessive flares may include16:
systemic absorption, and underuse may not 12-hourly) for 10 days for patients with
relieve symptoms.16, 21 t
topical corticosteroids immediate penicillin hypersensitivity.
(see Practice point 2)
TCS are safe medicines when used
appropriately.2 However, with prolonged
t
oral antibiotics Self-care for maintenance
treatment adverse effects may occur.2 t
sedating antihistamines at night and prevention of atopic
Atrophy of the skin is a more frequent (see Practice point 4) eczema
adverse effect of TCS, especially in the t
hospitalisation if condition is
elderly.16,22 Atrophied skin appears more unresponsive or herpes simplex infection Adherence to management strategies
transparent and bright, with telangiectasia (eczema herpeticum) is suspected. is essential in managing atopic eczema
(widened tiny blood vessels that cause red and avoiding flares. Skin must be
lines or patterns on the skin) and striae, If the patient is experiencing frequent flares kept hydrated.11
and is easy bruised. Scars and ulceration of their eczema, options include2,14,16,18:
may also appear. Application of TCS on the Advice pharmacists can provide to patients
t
changing the emollient to one with a
face can cause eruptions such as steroidal includes11,16:
higher lipid content
rosacea, acne and perioral dermatitis. t
avoid known irritants such as chemicals,
Systemic adverse effects are uncommon t
applying the emollient more often and
more liberally detergents, soaps, abrasives, wool or
and are mostly associated with the use of occlusive clothes
high potency topical steroids in large or t
attempting to identify and avoid irritants
denuded areas, under occlusion or in severe that might be causing flares t
avoid known allergens including foods,
skin disease.22 house dust mites and animal fur
t
applying corticosteroids 2–3 times a
week or on two consecutive days per t
avoid extremes of temperature and
Australian guidelines for TCS
week. humidity, which can lead to increased
To treat atopic eczema on the face and perspiration and overheating
flexures, apply hydrocortisone 1% once or For other treatment options for atopic
t
avoid very hot water, to avoid water loss
twice daily until the eczema has settled, eczema, see Practice point 4.
from the skin through evaporation
then continue to use an emollient.
t
apply emollients liberally two to four
Desonide 0.05% lotion can be applied to Bacterial infection
a hairy area once daily until the flare has times daily (especially after bathing),
settled, then continue to use an emollient. Secondary bacterial skin infections are very even when eczema is controlled
If these treatments are not effective, apply common in atopic eczema. Infection can t
avoid moisturisers that contain sodium
methylprednisolone aceponate 0.1% once develop if the skin barrier function lauryl sulfate (e.g. aqueous cream,
daily until eczema has settled (2–3 days up has broken down, allowing increased emulsifying ointment) as they may
to a maximum of 7 days).16,17 permeability to pathogens and an increase worsen eczema by damaging the skin
in the pH of the skin.2,16,23 barrier and cause irritation
If an atopic eczema flare occurs on
other parts of the body, initially apply a Management of bacterial infection t
add a dispersible bath oil to the
moderate-to-potent TCS once or twice includes17: bath water or spray oil onto wet skin
daily until the eczema flare has settled immediately after showering
t
using an antiseptic (e.g. triclosan 2%)
(usually 7–14 days) then continue to use t
avoid rubbing the skin dry as this may
in the bath water or sponged onto wet
an emollient.17 For atopic eczema in areas
skin (diluted) and left for 4 minutes cause unnecessary irritation – instead
where the skin is thick (soles and palms),
before showering off, to reduce the risk lightly pat skin dry with a soft towel
apply a potent-to-very potent TCS once
daily until eczema flare settles (may take of infection t
use soap and shampoo substitutes
up to 3 weeks), then continue to use (e.g. Cetaphil, DermaVeen, QV, Eulactol,
an emollient.17 Hamilton products).

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 Facts
John Bell saysBehind the Fact Card Atopic eczema and xerosis Pharmacist CPD Module number 260

Pharmacists can also reassure patients that allow irritants and allergens to enter her using fingertip units. You remind Jessica
if TCS are required to treat a flare, they are skin and cause her eczema to flare up. to use an moisturiser before applying
safe medicines to use and can be applied You recommend a soap-free wash as well the steroid cream, as it makes the steroid
liberally for a short period of time to bring
as a moisturiser. You also suggest that she more effective and reduces the itch.
the flare under control.19
use relaxation techniques to manage her You give her the PSA Self Care Fact Cards
stress level, especially as exams approach. on Eczema and dermatitis and Relaxation
Case study continued… techniques. You also encourage her
You reassure Jessica that short-
Avoiding eczema triggers, as much as to return to the pharmacy if she has
term use of a steroid cream of the
possible, is an important part of eczema another flare or any concerns about her
correct strength is beneficial and
management. Dry skin is a known trigger, eczema treatment.
safe in managing her eczema flares.
as is stress. You advise Jessica to use a
She should use it immediately when
moisturiser at least twice daily especially
a flare appears and continue its use
after bathing and avoid the use of soaps
until the flare has resolved, then cease
and shampoos. You explain that she must
using it. You demonstrate to Jessica
continue to use a moisturising treatment
how to measure the affected area and
to keep her skin hydrated. Dry skin can
the quantity of TCS she should apply,

References
1. DermNet NZ. Atopic eczema. 2015. At: www.dermnetnz.org/ 11. Australasian Society of Clinical Immunology and Allergy. 20. Improving general skin condition. In: eTG complete.
dermatitis/atopic.html Atopic dermatitis (eczema). 2010. At: www.allergy.org.au/ Melbourne: Therapeutic Guidelines; 2014. At: http://online.
2. Rigby D. Treatment and prevention of inflammatory skin health-professionals/hp-information/asthma-and-allergy/ tg.org.au/complete/eTG
conditions. mdBriefCase Australia. 2014. atopic-dermatitis?highlight=WyJlY3plbWEiXQ%20-%20 21. Corticosteroids: use in dermatology. In:eTG complete.
3. Pharmaceutical Society of Australia. Essential CPE: Skin sthash.678o0sOh.dpuf Melbourne: Therapeutic Guidelines; 2014. At: http://online.
conditions in older people. Canberra: PSA; 2013. 12. DermNet NZ. Dry skin. 2013. At: www.dermnetnz.org/ tg.org.au/complete/eTG
4. Pray WS, Pray JJ. Managing dry skin. US Pharmacist 2005;30(3). dermatitis/dry-skin.html 22. Carlos G, Uribe P, Fernandez-Penas P. Rational use of topical
At: www.medscape.com/viewarticle/502433 13. Scottish Intercollegiate Guidelines Network. Management corticosteroids. Australian prescriber 2013;36(5):158–61. At:
5. Atopic dermatitis. In: eTG complete. Melbourne: Therapeutic of atopic eczema in primary care. Edinburgh: SIGN; 2011. At: www.australianprescriber.com/magazine/36/5/article/1452.
Guidelines; 2014. At: http://online.tg.org.au/complete/ www.sign.ac.uk/pdf/sign125.pdf pdf
6. Fischer G. Atopic dermatitis. Australian Doctor 2010. 14. Patient.co.uk. Atopic dermatitis and eczema. 2015. At: www. 23. DermNet NZ. Complications of atopic dermatitis. 2014. At:
patient.co.uk/doctor/atopic-dermatitis-and-eczema www.dermnetnz.org/dermatitis/atopic-complications.html
7. National Eczema Society. What is eczema? At: www.eczema.
org/what-is-eczema 15. DermNet NZ. The causes of atopic dermatitis (eczema). 2015. 24. 24. Patient.co.uk. Fingertip units for topical steroids. 2014. At:
At: www.dermnetnz.org/dermatitis/atopic-causes.html www.patient.co.uk/health/fingertip-units-for-topical-steroids
8. The Royal Children’s Hospital Melbourne. Eczema guideline.
At: www.rch.org.au/clinicalguide/guideline_index/Eczema_ 16. Rossi S, ed. Australian medicines handbook. Adelaide: 25. Therapeutic Goods Administration. ARGOM Appendix 5:
Guideline Australian Medicines Handbook; 2015. Guidelines on OTC applications for specific substances. 2012.
17. General treatment of dermatitis. In: eTG complete. At https://www.tga.gov.au/book/p-q#paediatricanti
9. Lewis-Jones S. Dry skin and atopic eczema: an update on
the filaggrin story… what does it mean to you? Eczema Melbourne: Therapeutic Guidelines; 2014. At: http://online.
Association of Australasia. At: http://eczema.org.au/?page_ tg.org.au/complete/eTG
id=575 18. Pharmaceutical Society of Australia. Wound care in practice.
10. Eczema Association of Australia. Facts about eczema. At: Canberra: PSA; 2013.
www.eczema.org.au/?page_id=2 19. Manahan M. Taking the itch out of eczema. mdBriefCase
Australia. 2013.

10 inPHARMation June 2015 I © Pharmaceutical Society of Australia Ltd.

Atopic eczema and xerosis Pharmacist CPD Module number 260 Facts Behind the Fact Card

Assessment questions for the pharmacist

Atopic eczema and xerosis
Personal ID number: — — — — — —
Full name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pharmacy: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Suburb: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Circle one correct answer from each Please submit your assessment by
of the following questions. 31 July 2015
Before undertaking this assessment, you need Submit answers
to have read the Facts Behind the Fact Card
article and the associated Fact Cards. Submit online at www.psa.org.au/selfcare Accreditation number: CS150006
This activity has been accredited by PSA as a Fax: 02 6285 2869 This activity has been accredited for 2 Group 2 CPD
Group 2 activity. Two CPD credits (Group 2) credits suitable for inclusion in an individual pharmacist’s
will be awarded to pharmacists with four out Mail: Self Care Answers CPD plan. 
of five questions correct. PSA is accredited by Pharmaceutical Society of Australia
the Australian Pharmacy Council to accredit PO Box 42
providers of CPD activities for pharmacists DEAKIN WEST ACT 2600
that may be used as supporting evidence of Please retain a copy for your own purposes.
continuing competence. Photocopy if you require extra copies.

1. Xerosis is a trigger for flares of 3. A 25-year-old patient comes into 5. The MOST appropriate TCS
eczema. Which of the following the pharmacy asking for treatment preparation for the treatment of a
statements about emollients is for a moderate-to-severe eczema severe flare of eczema on thickened
CORRECT? flare behind the knee. From the skin on the elbow would most likely
options below, which is the MOST be:
a) Emollients are used to maintain the appropriate?
moisture content of the skin. a) Hydrocortisone 1% cream.
a) Recommend the use of an emollient.
b) An application of an emollient can b) Desonide 0.05% lotion.
reduce pruritus. b) Recommend a once daily
c) Betamethasone dipropionate 0.05%
application of hydrocortisone 0.5%
c) Patients with atopic eczema should ointment.
cream.
have ongoing treatment with d) Betamethasone valerate 0.02%
emollients. c) Recommend clobetasone butyrate
ointment.
0.05% cream and refer patient to a
d) All of the above.
doctor.
2. The link between xerosis and eczema d) None of the above.
is attributed to:
4. From the following, choose the
a) Epidermal dehydration and CORRECT statement.
deterioration of the barrier function
of the skin. a) Asthma and allergic rhinitis are
rarely seen in patients who had
b) Development of eczema in
atopic eczema in childhood.
childhood.
b) Managing eczema involves avoiding
c) An increase in pruritus and
triggers, using moisturisers and
subsequent scratching.
topical corticosteroids.
d) None of the above.
c) Emollients are only used for treating
acute eczema flares.
d) Potent corticosteroids are always the
preferred therapy for flexures and
skin folds.
inPHARMation June 2015 I © Pharmaceutical Society of Australia Ltd. 11