dermatology treatment guidelines

8/12/2019 Dermatology Treatment Guidelines

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DERMATOLOGY TREATMENTGUIDELINES

Folder Ref No: 46

Signed: ... Date : .Clinical Governance Lead GP

Signed: ...... Date : .Executive Director

Date of Issue: June 2008Version No: 1.4

Date of Review: June 2010Author: Val Anderson, Dermatologist Nurse


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If you need further copies of this document please contact VickyBawn, Quality and Performance Support Manager, 0117 330 2454

Organisation Name

Document status: (draft or current as applicable)

Version Date Comments

1.0 03/03/08 Valerie Anderson submitted references etc1.2 03/04/08 Format of guidelines amended

1.3 16/04/08 Sent to Val for approval of format1.4 28thApril 2008 Sent to P&G ratification Group. Approved

1.4 22ndMay 2008 Approved by Integrated GovernanceCommittee


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CONTENTS PAGE

1.0 Introduction 4

2.0 Treatment and Management of Psoriasis (Adult) 5

2.1 Appendix A

Rationale for the Treatment of Psoriasis 6

3.0 Treatment and Management of Eczematous andPsoriatic Scalp Problems (Adult) 9

3.1 Appendix CRationale for Treatment and Management ofEczematous and Psoriatic Scalp Problems 10

4.0 Treatment and Management of Atopic Eczema (Adult) 13

4.0 Treatment and Management of Atopic Eczema (Child) 14

4.1 Appendix E

Rationale for the Treatment and Management of Atopic Eczema 155.0 Treatment and Management of Scabies (Adult) 19

5.1 Table 3 - Guidelines for the Effective Treatment of Scabies 20

5.2 Table 4 - Extra Precautions to be taken in cases ofCrusted Scabies 21

5.3 Table 5 - Action Plan To Effectively Manage One orMore Cases of Scabies in a Nursing/Residential Home 21

5.4 Appendix GRationale for Treatment and Management of Scabies 22

6.0 Treatment and Management of Hand and Foot Eczema (Adult) 246.1 Appendix I

Rationale for the Treatment and Management of Hand andFoot Eczema 25

7.0 Table 1 - Emollients 30

71. Table 2 Topical Steroids Potencies 31

8.0 Application of Emollients (moisturisers) Advice Sheet 32

9.0 Audit Tool 33

10.0 Equality impact assessment 33

10.0 References 33

11.0 Bibliography 33

12.0 National Patient Safety Agency fire hazard leaflet


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DERMATOLOGY TREATMENT GUIDELINES

1. Introduction

Purpose

To act as a guidelines for health professionals, who are not dermatology specialists,in the care of chronic inflammatory dermatitis in primary care.

Principles

This guideline is intended to be used within the competency levels of those referringto it. If the health professional does not feel fully competent advice is to be soughtfrom the dermatology nurse specialist.


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2.0

Treatment and management ofPsoriasis (Adult)

Holistic assessment and history taken.Skin assessed, extent of disease andpresent treatments recorded.

Treatment regimen planned with patientfollowing agreed protocols

General regimen plusthat for each affectedarea.

Affectedarea

First line treatmentReview at 4-8 weeks

Second line treatment tostart if poor response notedby week 4-8.

Face, earsand hairline

- Mild topical steroideg, 1% hydrocortisoneoint. Or Alphosyl HCcream.- Ears- As above plustopical steroid drops tocanal.

Use moderate potency topicalsteroid eg. Eumovate oint.plus short contactdithranol/dithrocream tothickened areas particularilyaround hairline.

ChronicPlaque

- Vit.D analogue or- Dithrocreamshort/moderatecontact plus moderatepotency topicalsteroid e.g. BetnovateRD oint. +/- 5% tar orStiedex LP cream.

Thicker plaques may needdithranol in lassars paste pluspotent topical steroid eg.diprosalic oint. +/- duodermocclusion or DovobetOintment OD ( max 4 weekuse then revert to first linetreatment).

Guttate

Psoriasis

Mild topical steroid +/-

tar eg Alphosyl HCcream+/- vit D analogueConsider conjunct reffor TL01 UVB

Try moderate potency steroid

eg Eumovate oint. +/- vit Danalogue or dithrocream tothicker plaques.

FlexuralPsoriasisand Genitalarea

Mild/moderate topicalsteroid eg 1%hydrocortisone oint or .Trimovate cream

Consider a higher potencysteroid for 3-4 days such asLocoid C.

Followingassessment aplanned teachingprogramme will beimplemented, whichaims to providesupport and enablethe patient tounderstand his/hercondition andrecognize the mosteffective treatments.This will includeadvice on use ofemollients, whenwashing and avoidingastringent substancesthat may dry skin.Encouraging tomoisturise skin

regularly as part oftheir skin careregimen.- Use a soap

substitute, suchas AqueousCream orEmulsifyingOintment.

- Use an emollientbath additive,such as Polytar ,Oilatum,E45 orBalneum Plus

- Moisturise skin

at least daily witha toleratedemollient. (Seetable 1 foremollient advice)

Plantar andpalmarPsoriasis

Potent topical steroideg diprosalic oint,elocon oint or

dermovate oint.

Try polythene occlusion oftopical agents, for one weekmax..Soften hyperkeratotic

areas with keratolytic agents

Moderate clearance should be noted by weeks 6-8. If yes continue and modify for discharge aroundweek 12. If not then referral to Secondary care may be required; this also remains an option if the patienthas a flare at any time.Refer to Appendix A for the rationale behind treatment protocols, methods of patient review anddischarge planning. Refer to Appendix B for teaching plan.


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2.1 Appendix ARationale for the treatment of Psoriasis

Action RationaleCarrying out a holistic assessment. Skin conditions can often be related to

other health problems and certainmedication. Also there can be a greatpsychological and social impact of thedisease. Environmental factors and

triggers like stress, trauma and alcoholintake can exacerbate psoriasis.Extent of psoriasis and present treatmentsrecorded.

A clear assessment of skin is vital so thatcorrect treatment can be identified and thatimprovement or flares can be recordedcomparatively. Previous experience oftreatments is useful firstly to determinetheir effectiveness, secondly to gain insightinto the patients perspective and factorswhich may influence their willingness tocontinue with further treatment.

A regimen is planned with the patientfollowing agreed protocols.

It is vital to work with the patient andnegotiate achievable goals for treatment,

the patients physical ability, andunderstanding, external commitments andmotivation need to be taken into account.Agreed treatment protocols are vital innursing practice, thus ensuring uniformityand good standards of care; additionally asa formal record they act as a referenceguide when considering accountability.

The regimen will include some core goalsand will incorporate a formal teaching plan.

The belief is held that patients will follow aparticular route through treatment andachieve common or core objectives;acknowledging that patients haveindividual needs, these pathways will be

altered accordingly. It is vital that atreatment regimen facilitates patienteducation to enable understanding of theircondition and the most effective treatment.Approaching core goals in this wayencourages uniformity and maintenance ofcare standards in a formal way.

Advise to use of soap substitutes andemollients.

Soaps and shampoos are astringent andcan dry the skin. The aim is to improve thegeneral skin condition by moisturising andremoving scale. This emollient preparationprimes the skin for other topical agents andreduces cracking making the skin morecomfortable.


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Appendix ARationale for the treatment of Psoriasis

Action RationalePatient education is aimed at enabling thepatient to understand his/her skin conditionand recognize the most effectivetreatments.

Patients need a clear understanding oftheir skin condition in order to comprehendthe benefits of certain treatments. Toresand Tilford link patient education withpatient satisfaction, which in turn prompts

a change in behaviour. This of course isvery relevant to the extent to which thepatient will comply with the treatmentprotocol suggested to them. In addition, ifpatients are to recognize the benefits oftheir potential treatments, they mustunderstand their actions and possible sideeffects. E.g. correct application of topicalsteroids can minimize potential side effectsand careful application of dithranolpreparations can avoid staining andburning to unaffected areas.

Using topical steroids in the treatment of

psoriasis.

Mild to moderate potency topical steroids

are useful in the treatment of psoriasis.They reduce inflammation and are oftenthe first choice to areas such as face, ears,hairline and flexures. In flexural areas theyare commonly combined with antifungals.Plus other combinations e.g. with salicylicacid can reduce scaling and flattenhyperkeratotic areas.

Potent topical steroids are only used tospecific areas and their progress andusage are monitored carefully.

Sometimes there can be a reboundphenomenon occur when potent topicalsteroids are stopped. Additionally, it isbeneficial to reduce to a moderate to mildpotency steroid to limit the long - term side

effects, however with correct usage tospecific areas e.g. hyperkeratotic plaques,these side effects can be kept to aminimum.

Using tar based products in the treatmentof psoriasis.

Coal tar has anti-inflammatory andantiscaling properties it also has anantimitotic effect however its exact actionis unclear. Tar products may cause patientcompliance problems, as they are messyand odorous. However modern tarproducts are a little better tolerated.

Using vitamin D analogue creams. These are thought to act by enhancing thedifferentiation of epithelial cells, a stage ofepidermal development missing in psoriaticskin. These treatments are well tolerateddue to ease of application, plus negligiblemess and smell.


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Appendix ARationale for the treatment of Psoriasis

Action RationaleUsing dithranol preparations in thetreatment of psoriasis.

Dithranol has an antimitotic action, therefor slowing down the rapid cell division.Dithranol is available as cream, ointmentor paste. The vehicle of choice depends onthe site affected, thickness of plaques as

well as patient preferences and timeavailable. It is commonly used for shortcontact treatment, where by the patient willapply it to specific psoriatic plaques,leaving it in situ for up to one hour thencarefully washing it off. The benefits of thismethod are that staining and irritation canbe minimalised.

Using occlusion to thicker plaques. Occlusion concentrates the effects of themoisturiser and topical steroid. It is auseful way of softening areas ofhyperkeratosis.

Methods of patient review and discharge planning

Action RationaleReview patients regularly whilstundergoing treatment.

To assess efficacy of treatment.Observe for signs of soreness or irritationdue to treatment.Provide support and encouragement clearance may take up to 12 weeks, ifmorale is poor compliance may also suffer.To provide a forum for patient education.

Assess and record skins appearance ateach visit.

To observe for scale reduction, smoothing(and staining if using dithranol).Observe for erythema or soreness.For clear record keeping and showingawareness of personal accountability.

Building rapport, being accessible, flexibleand contactable.

The aim of the treatment plan is to givepatients the confidence to treat themselvesat home and manage their own skincondition. Being an effective resource canfacilitate this process.

Reducing frequency of visits as skinimproves, guiding patients throughdecision making and making use of thetreatments they have available

Encouraging patients to use theirknowledge of their condition andtreatments. To promote independence.

Have clear guidelines of patient routes forre-referral once discharged. To reduce misunderstandings, to promotean efficient service.


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3.0

Treatment and management ofeczematous and psoriatic

scalp problems (Adult)

Holistic assessment and history taken.Scalp assessed, extent of affected

areas and present treatment recorded.

.Treatment regimenplanned withpatient following agreed

protocols.Incorporating the core

plan of care.

Presentation of scalpcondition

First line treatment.Review at 1-4weeks

Second linetreatment, to bestarted if poorresponse notedby week 4.

Psoriaticwithlight scale

- Vit D analoguescalp application egDovonexorTar/sulphur/salicylic acid eg Cocois oint

Try adding apotent topicalsteroid scalpapplication egdiprosalic scalpapplication.

Psoriaticwith thickscale

-Tar/sulphur/salicylicacid eg Cocois oint+/- a steroid scalpapplication egdiprosalic.- Soften thickerscale via occlusionof keratolytic agentor emollient

Try occludingTar/sulphur/salicylic acid egCocois ointnocte or shortcontactdithrocream plussteroidapplication

Eczematous dry and

scaly.

- Emollient to liftscale and ease

dryness- Steroid scalpapplication inaqueous base

Tar/sulphur/salicylic acid eg

Cocois oint maybe tolerated tospecific areas.

Core plan of care.This follows initialassessment and is aplanned teaching programthe implementation of thisprovides support, enabling

the patient to understandhis/her condition andrecognize themost effective treatments.

The educative program willcover cleansing of thescalp. If psoriatic in originthen a tar based shampoocan be used, eg. Polytar,Alphosyl or T gel.If tar is not tolerated then amild baby shampoo isrecommended.

An eczematous scalp maytolerate a mild babyshampoo eg Immuderm orVantage, if not a light soapsubstitute can be used egDermol 500. Eczematous

inflamedand weepy.

- Steroid scalpapplication inaqueous base egsynalar gel or dotwith topical steroid/anti bacterial toweepy areas egFucibet.

Take swab formicroculture andsensitivity.Consider needfor antibiotics +/-refer toconsultantdermatologist.

Moderate clearance should be noted by 6-8 weeks. If yes continue and modify treatment fordischarge around week 10-12. If not then referral to Secondary care may be required; this alsoremains an option if the scalp flares at any time.

Refer to Appendix C for the rationale behind treatment protocols, methods of patient reviewand discharge planning. Refer to Appendix D for teaching plan.


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3.1 Appendix CRationale for treatment and management of eczematous andpsoriatic scalp problems


other health problems and certainmedication. Also there can be a greatpsychological and social impact of the

disease. Environmental factors andtriggers like stress, trauma and alcoholintake can exacerbate the skin condition.

Extent of psoriasis and present treatmentsrecorded.


A regimen is planned with the patient

following agreed protocols.

It is vital to work with the patient and

negotiate achievable goals for treatment,the patients physical ability, andunderstanding, external commitments andmotivation need to be taken onto account.Agreed treatment protocols are vital innursing practice, thus ensuring uniformityand good standards of care; additionally asa formal record they act as a referenceguide when considering accountability.


The belief is held that patients will follow aparticular route through treatment andachieve common or core objectives;acknowledging that patients haveindividual needs, these pathways will bealtered accordingly. It is vital that atreatment regimen facilitates patienteducation to enable understanding of theircondition and the most effective treatment.Approaching core goals in this wayencourages uniformity and maintenance ofcare standards in a formal way.


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Appendix CRationale for treatment and management of eczematous andpsoriatic scalp problems

Action RationaleEducating the patient about cleansinghis/her scalp.

Cleansing allows scale, crusted exudatesand residual topical preparations to belifted from the scalp. The method ofcleansing will alter depending on the

condition. E.g. an eczematous scalp needsa mild cleansing agent with gentleagitation, whereas a scale is actively liftedfrom a psoriatic scalp during washing.This educative process informs the patientof the correct technique (e.g. to wash hairseparately from the bath or shower asshampoo suds will drizzle down thepatients back and may aggravate theirskin.), plus acknowledging the therapeuticbenefits of additives, such as tar for itsantimitotic effects.It introduces the concept of planning a

regular treatment regimen at home.

Using a vitamin D analogue to a lightlyscaling psoriatic scalp.

This is a well-tolerated treatment as it isodourless and easy to use, which areimportant factors when consideringcompliance.Patients should be informed that no morethan 60mls of solution to be used In oneweek, or less if also using cream/ointment,due to the risk of hypercalcaemia.

Using a mix of tar/sulphur/salicylic acid ona scaly scalp.

Initially messy to use, but with correctapplication it can be used without too muchgrease in the hair.The greasy mixture softens scale allowingit to be lifted with a comb. The tar acts asan antimitotic, whilst the sulphur andsalicylic acid work to reduce the surfacescale.

Using liquid paraffin to scalp/with occlusion This is a way of moisturizing a dry scalp;occlusion will concentrate these effectsand help to loosen thicker scale.

Using dithrocream to scalp. Fixed psoriatic scale may benefit fromdithrocream, which has an antimitoticeffect.The patient must be aware of the irritant

and staining effects and the importance ofavoiding contact with the face and eyes.Using a topical steroid on the scalp. The scalp can tolerate potent topical

steroid applications. These have an anti-inflammatory effect and are thereforeuseful both in the treatment of eczema andpsoriasis. Combinations with for instancesalicylic acid in Diprosalic can bebeneficial.

Regularly reviewing a weepy scalp. Takinga swab for micro culture and sensitivity.

Staph. Aureus can act as a flare factor (8)The need for oral antibiotics needs to beassessed.


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Appendix CRationale for treatment and management of eczematous andpsoriatic scalp problems



To assess efficacy of treatment.Observe for signs of soreness or irritation

due to treatment.Provide support and encouragement clearance may take up to 12 weeks, ifmorale is poor compliance may also suffer.To provide a forum for patient education.

Assess and record skins appearance ateach visit.

To observe for scale reduction, smoothing(and staining if using dethrone.), improvedintegrity and less excoriations.Observe for erythema or soreness.For clear record keeping and showingawareness of personal accountability.

Encourage the patient to involve a relativeor friend in treatment. Invite the individualto attend a demonstration session of howtreatment should be applied.

The scalp is very difficult to treatindependently; having someone who iscompetent and confident to do thetreatment for them will aid theircompliance.





Have clear guidelines of patient routes forre- referral once discharged. To reduce misunderstandings, to promotean efficient service.


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4.0

Treatment and management ofatopic eczema. (Adult)

Holistic assessment and history taken.Skin assessed, extent of affected


.Treatment regimenplanned with patientfollowing agreedprotocols.Incorporating thecore plan of care.

Presentation ofconditionand areasaffected.


Second linetreatment, to bestarted if poorresponse noted 4 -8 weeks

Dry scalingand inflamedface, earsand flexures

Use a mild topicalsteroid to theseareas twice daily

Step up to amoderate potencysteroid for one weekthen review.

Dry, scaly

and itchytrunk andlimbs.

Use moderate

potency topicalsteroid twice daily.Plus see emollientadvice on table 1.Consider oralantihistamine.

Step up to potent

steroid to persistentareas Or try wetwraps with moderate/mild potencysteroid. Review 1-2weekly.

Dry andinflamedtrunk andlimbs.

Use a potent topicalsteroid in a creamform initially, andthen reduce to amoderate potencyas inflammationreduces.

Try wet wraps withmoderate potencysteroid, review 1-2weekly, and thenreduce to tubularcoverings.

Inflamed,fissured,weepy andcrusting to allareas.

Refer to table 1. foremollient advice.Use potent topicalsteroid plus antibacterial agent. Usediluted KMNO4 ascompress/soaks toweepy areas.Reduce to moderatepotency steroid asskin improves.

Send a skin swab formicro culture andsensitivity, consideroral antibiotics.Once potentialinfection has settledtry paste bandagesto fissured andexcoriated areas.Revert to tubularcoverings when rawareas have healed.

Core plan of care.This follows initialassessment and is aplanned teachingprogram theimplementation ofthis provides support

and guidance,enabling the patientto understandhis/her condition andrecognize the mosteffective treatments.The educativeprogram willemphasize theimportance ofavoiding astringentsubstances such assoaps andshampoos.

Soap substitutes arerecommended, inaddition to an oiladditive tobath/wash water.Skin should bemoisturised at least2/3 times daily orwhenever skin is dryAll topical steroidapplications shouldbe used inconjunction withemollients. See table

1. for further details.Where possibletubifast coveringsare recommended touse with topicalapplications.

Lichenifiedareas.

Moderate to potenttopical steroid.

Try paste bandagesto affected areas ora thin hydrocolloid tosmaller areas.

Moderate clearance should be noted by 8 10 weeks. If yes continue and modify treatment fordischarge around week 12-14. If not then referral to Secondary care may be required; thisalso remains an option if the skin flares at any time.Refer to Appendix E for the rationale behind treatment protocols, methods of patient reviewand discharge planning.


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4.0

Treatment and management ofatopic eczema. (CHILD)

Holistic assessment and history taken.Skin assessed, extent of affected


.Treatment regimenplanned with patientfollowing agreedprotocols.Incorporating thecore plan of care.

Presentation ofconditionand areasaffected.


Second linetreatment, to bestarted if poorresponse noted 4 -8 weeks

Dry scalingand inflamedface, earsand flexures

Use a very mildtopical steroid tothese areas twicedaily (hydrocortisone0.5%)

Step up to a mildpotency steroid forone week thenreview.

Dry, scaly

and itchytrunk andlimbs.

Apply emollient (see

emollient advice ontable 1). Consideroral antihistamine.

Use mild topical

steroid to persistentareas Or try drywraps overemollients. Review1-2 weekly.

Dry andinflamedtrunk andlimbs.

Use a mild topicalsteroid initially, andthen reduce toemollients only asinflammationreduces.

Try dry wraps withmild potency steroid,review 1-2 weekly.

Inflamed,

fissured,weepy andcrusting to allareas.

Refer to table 1. for

emollient advice.Use mild/moderatetopical steroid plusanti bacterial agent.Reduce steroidpotency as skinimproves.

Send a skin swab for

micro culture andsensitivity, consideroral antibiotics.Once potentialinfection has settledtry paste bandagesto fissured andexcoriated areas.Revert to tubularcoverings when rawareas have healed.

Core plan of care.This follows initialassessment and is aplanned teachingprogram theimplementation ofthis provides support

and guidance,enabling the patientto understandhis/her condition andrecognize the mosteffective treatments.The educativeprogram willemphasize theimportance ofavoiding astringentsubstances such assoaps andshampoos.

Soap substitutes arerecommended, inaddition to an oiladditive tobath/wash water.Skin should bemoisturised at least2/3 times daily orwhenever skin is dryAll topical steroidapplications shouldbe used inconjunction withemollients. See table1. for furtherdetails.Where possibletubifast coveringsare recommended touse with topicalapplications.

Lichenifiedareas.

Mild to moderatetopical steroid.

Try paste bandagesto affected areas or

a thin hydrocolloid tosmaller areas.

Moderate clearance should be noted by 8 10 weeks. If yes continue and modify treatment fordischarge around week 12-14. If not then referral to Secondary care may be required; thisalso remains an option if the skin flares at any time.


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4.1 Appendix ERationale for the treatment and management of atopic eczema


other health problems and certainmedication. Also there can be a greatpsychological and social impact of thedisease. Environmental factors and

triggers like stress can aggravate eczemaExtent of eczema and present treatmentsrecorded.



It is vital to work with the patient andnegotiate achievable goals for treatment,the patients physical ability, and

understanding, external commitments andmotivation need to be taken into account.Agreed treatment protocols are vital innursing practice, thus ensuring uniformityand good standards of care; additionally asa formal record they act as a referenceguide when considering accountability.


The belief is held that patients will follow aparticular route through treatment andachieve common or core objectives;acknowledging that patients haveindividual needs, these pathways will bealtered accordingly. It is vital that a

treatment regimen facilitates patienteducation to enable understanding of theircondition and the most effective treatment.Approaching core goals in this wayencourages uniformity and maintenance ofcare standards in a formal way.


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Appendix ERationale for the treatment and management of atopic eczema

Action RationaleAdvise to use of soap substitutes andemollients.

Soaps and shampoos are astringent andcan dry the skin. Advocating an effectiveskin care regimen using emollients is theessence of eczema management. Bathingwith an emollient is a moisturizing and

cleansing experience. (9)

The cleansingaction removes dead skin cells andresidual topical medicaments. Bathing withemollients offer further treatment optionse.g. antibacterial for widespreadexcoriation or antipruritic for a very itchyskin.Emollients act to reduce loss of skinmoisture and help restore the lipid barrierimbalance. (10) For the emollient to work asan effective barrier it must be reapplied atleast 2-3 times daily, 4-5 times if possible.The range of emollients is wide and varied

so the patient needs to be clearly advisedso that they can make an informed choiceof the one which suits them and their skin.

Patient education is aimed at enabling thepatient to understand his/her skin conditionand recognize the most effectivetreatments.

Patients need a clear understanding oftheir skin condition in order to comprehendthe benefits of certain treatments. Tonesand Tilford link patient education withpatient satisfaction, which in turn promptsa change in behaviour. This of course isvery relevant to the extent to which thepatient will comply with the treatmentprotocol suggested to them. In addition, ifpatients are to recognize the benefits of

their potential treatments, they mustunderstand their actions and possible sideeffects. E.g. correct application of topicalsteroids can minimize potential sideeffects.

All topical steroid applications should beused in conjunction with emollients. Wherepossible tubifast coverings arerecommended.

Using a combination of topical steroids andemollients works very effectively for thetreatment of eczema. Topical steroids aremore rapidly absorbed when applied towell moisturised skin. The ideal is to applythe moisturiser 20 minutes prior to steroidapplication. Tubifast coverings hold creamsand ointments in place, providing mildocclusion and can prevent the individualharming their skin if they scratch.

Using topical steroids in the treatment ofeczema.

Topical steroids suppress varioussystematic components of theinflammatory reaction. Topical steroids canbe combined with antibacterial andantifungal agents.


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Action Rationale.Potent topical steroids are only used tospecific areas and their progress andusage are monitored carefully.

It is important to regularly review a patientusing a potent topical steroid, so that asskin improves a step down to a moderatethen mild potency steroid can be made tolimit the long - term side effects, however

with correct usage, these side effects canbe kept to a minimum.

Patient education should include thecorrect usage of topical steroids.

Generally people are concerned aboutusing topical steroids. It is important toallay these fears with some clear facts andguidelines that can be followed.Reassuring the patient about these issuescan improve patient compliance andensure correct usage. Although overusecan be a problem so can under use. It isbetter that the correct quantities are usedfor a shorter length of time, than too littlesteroid over a long length of time with

frequent flares.Recommending oral antihistamines. These can be useful short term to relieve

pruritis and may help to break an itchscratch cycle, particularly if scratching isoccurring in the sleep. Depending onchoice they can have a sedative effect.

Using wet wraps in eczema management. Often used to control itch scratch cycle.They are not suitable for weepy or infectedeczema. They involve applying a warm,moist tubifast covering over skin treatedwith emollient and a mild topical steroid.This creates a cooling effect throughevaporation, rehydration via emollients,

protection from scratching, allowingexcoriations to heal and improved steroidabsorption.

Using potassium permanganate (KMN04)to weepy areas.

This is an astringent oxidizer, which isused for its cleansing/antiseptic effects andfor its drying effects on weepy skin. It canbe an irritant and care must be taken todilute it and use correctly. (See table 5)

Taking a skin swab for micro culture andsensitivity.

There are many topical agents availablethat have antimicrobial properties. Thesemay be useful in the management oflocalized infection, however if there isgeneralized infection then systemicantibiotics may be necessary. A moist skinswab should be taken to clarify antibioticsensitivity.It is vital to be aware of the potential ofviral and fungal infections. (See table 6).


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Action RationaleUsing paste bandages. These are helpful in the management of

excoriated, inflamed and lichenifiedeczema. They are occlusive and offersimilar benefits to the wet wraps. There area variety of paste bandages available; the

choice depends on skin presentation andpatient tolerance.

Using occlusion to thicker lichenified areas. Occlusion concentrates the effects of themoisturiser and topical steroid. It is auseful way of softening areas ofhyperkeratosis.

Methods of patient review and discharge planning.


To assess efficacy of treatment.Provide support and encouragement

clearance may take 12 weeks or more, ifmorale is poor, compliance may alsosuffer.To provide a forum for patient education.

Assess and record the skins appearanceat each visit.

To monitor the response to treatment andto make modifications to treatment plan tomeet changing patient needs.Observe inflammation, weeping or othersigns of infection.For clear record keeping and showingawareness of personal accountability.



If appropriate involve a relative orsignificant other in treatment andeducation.

Eczema is a chronic skin disease that mayflare intermittently; if the patient hassupport from a relative/partner then it mightstrengthen their ability to cope. Also topicaltreatments are lengthy and messy helpwith these at home is always welcomed.

Reducing frequency of visits as skinimproves, guiding patients throughdecision making and making use of the

treatments they have available


Have clear guidelines of patient routes forre-referral once discharged.

To reduce misunderstandings, to promotean efficient service.


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5.0

Treatment and management ofscabies (Adult)

Holistic assessment and history taken.Skin assessed, signs of infestation

noted. Treatment to date of patient plusfamily members and contacts recorded.

.Treatment regimenplanned with patientfollowing agreed protocols.Incorporating the core

plan of care.

Presentation

of condition

(See belowfor clinicalsigns).

First line treatment.Review at 7-10days.

Second linetreatment,

Clinicalsigns ofinfestationwith nopreviousscabicide

treatment.

Treat with Malathionor Permethrinfollowing guidelineson table 3.Repeat after tendays.

Check that guidelineswere followed rigidly,reassure and guidethrough a furtherapplication. UsePermethrin if not

pregnant adult.

Previoustreatmentwithscabicide,clinical signsstill evident.

Offer a furtherapplication ofscabicide; PreferablyPermethrin if nonpregnant adult.Review patientsunderstanding ofguidelines.

A maximum of weeklyapplication for 3 weeksshould not beexceeded.Therefore give thethird application, ifalready given guidethrough emollienttherapies and reviewin 10 days.

Clinical

signs ofcrustedscabies

Instigate treatment as outlined previously. Take

extra precautions as highlighted on table 4.Lead a coordinated approach in treating theindividual, tracing contacts and preventingspread of scabies, particularly in the care setting.

Core plan of care.This follows initialassessment and is aplanned teaching programthe implementation of thisprovides support, enabling

the patient to understandhis/her condition andunderstand the importanceof treating it correctly.

The educative program willcover correct application oftreatments, the importanceof tracing close contactsand ensuring that they alsoreceive treatment.

Residualpruritic rash,posteffectivescabicidetreatment.

Instigate the use of soap substitute andemollients as outlined in the treatment of eczemaprotocol. Sometimes a cream containingcrotamiton (Eurax) can be a useful antipruritic,which also has an anti-scabetic effect.

(9)

Otherwise a mild to moderate potency topicalsteroid will calm the inflammatory reaction. Anti-histamines can be helpful.

Clinical signsof scabies are: Burrows commonly affecting sides of fingers, wrists and ankles.Nodular burrows seen in genital area. Pruritic scabies rash also seen in axilla, umbilicus, buttockand thighs. Skin is intensely itchy and may become eczematous and secondarily infected. Itchingmay continue 2-3 weeks post treatment. If pruritis continues after 4 weeks review with consultantdermatologist.

Refer to Appendix G for the rationale behind treatment protocols, methods of patient review anddischarge planning. Refer to Appendix H for teaching plan.


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5.1 Table 3 Guidelines For The Effective Treatment of Scabies

Action Rationale

All contacts need to be notified,and a coordinated treatmentregimen instigated. This includesclose family members and sexualcontacts. It is vital that all contactsare treated simultaneously and

effectively. Contact tracing should go back 6

weeks.

Scabies can burrow into the skinduring skin-to-skin contact.Symptoms of scabies may notappear for up 4 weeks followingtransmission, so potentially allcontacts may be affected.

Poor clearance or retransmissionof scabies is often due to failureto treat all close contacts.

Before treatment it is important toread the accompanying leaflet.

It is important to be aware ofpotential hazards of thetreatment. Plus treatment timesand recommended applicationmay vary from product to product.

It is best to do the treatment inthe evening before going to bed.Skin should be cool and dry,avoid bathing before applyingcream.

This will ensure that the treatmentwill be most effective and kept onfor the planned length of time.

The solution or cream should beapplied to the whole body fromthe neck down, it is important toinclude skin creases andgenitalia. Pay particular attentionto behind ears and knees, underarms and breasts. Thecream/lotion should be appliedunder toe and fingernails, whichneed to be kept short; plusbetween toes and to soles of feet.

It is vital that all areas are treatedeffectively to avoidretransmission.

Keeping fingernails short allowseffective treatment under nailsand reduces excoriations.

Flexural areas may harbourresidual mites if not treatedcorrectly, which will lead toretransmission.

Ensure cream is reapplied after

washing hands or using the toilet.

Cream must be in place for the

prescribed time period to beeffective.

Leave cream on for 8 to 12 hoursas advised. Overnight is ideal.

This will ensure that the treatmentwill be most effective and kept onfor the planned length of time.

Have a bath or shower and applybland moisturiser e.g. aqueouscream or E45.

Residual cream/lotion should beremoved. Moisturising skin willcalm irritation.

All clothes worn for the previoustwo days plus bed linen should bewashed and it is advised that thehome is vacuumed at the end oftreatment.

Mite may be transferred toclothing, bedding etc. Normalwashing is sufficient.

Systematic laundering coincidingwith treatment will reduce the risk

of retransmission. If there is a delay in treating any

contacts then if possible furthercontact should be avoided untiltreatment is complete.

This is vital to preventretransmission.

There is great importance inthorough and effective contacttracing.

Adapted from Hughes E & Van Onselen J (2001) Dermatology Nursing A Practical Guide. ChurchillLivingstone and Poulsom WJ (1999) Scabies Policy for Control in the Community Avon HealthAuthority.


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5.2 Table 4 Extra Precautions to be taken in Cases of Crusted Scabies

Action Rationale

All actions on table 3 should befollowed in addition to these extraprecautions.

The basic principles of scabiesmanagement should still befollowed to ensure effectivetreatment.

In crusted scabies there arethousands of mites and therefore

may be resistant to treatment. Isolate the affected individual in a

single room. Crusted scabies is highly

infectious so isolation isnecessary to avoid spread ofinfection.

Establish which nurses, carersand residents have had contact.Instigate treatment.

If the patient receives input fromnurses or carers, or is in aresidential/nursing home, then thepotential number of contacts ismuch greater. See action planoutlined below (Table 5).

Use disposable gloves andaprons.

Bag laundry as infected linen.

To prevent spread andtransmission of scabies.

Daily damp dust and vacuum theroom.

Mites are spread in largenumbers into the environment.

Discard creams/ointmentspreviously used by patient.

There is the potential that mitescould survive in the cream andreinfect the patient.

Adapted from Hughes E & Van Onselen J (2001) Dermatology Nursing A Practical Guide ChurchillLivingstone.

5.3 Table 5 Action Plan -To Effectively Manage One or More Cases ofScabies in a Nursing/Residential Home

Action Plan Nominate one person who will coordinate the treatment plan, trace contacts,

keep individuals informed, and Monitor the response to treatment andcoordinate with the infection control department.

Clearly identify the source of the scabies. Is it from within the home or due toa transfer in or new resident? Has the patient attended any appointmentsoutside the home? Do any of the staff work in other homes?

Check all staff and residents for signs of scabies. Decide if isolation is necessary. Is it crusted scabies? If so follow guidelines

above.

Trace contacts generally treat all staff that have had skin-to-skin contact,the individuals who this staffs have nursed, and the infected persons familywith whom they have had contact. Staff families are not usually treated unless

they are the infected case. Instigate treatment as outlined previously.

Ensure the infected residents creams and ointments are discarded in casethey are harbouring mites.

All residents should have their own towels. The need for careful hand washing should be reiterated to all staff.

Laundering and cleaning as outlined previously should be carried out.Adapted from the directives in Poulsom WJ (1999) Scabies-Policy for Control in Nursing&Residential Homes Control of Infections Unit Avon Heath Authority.


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5.4 Appendix GRationale for treatment and management of scabies

Action RationaleCarry out a holistic assessment. A holistic assessment, will assist in

planning a treatment regimen, it allowssocial and environmental factors to betaken into account.

Assess and record skin condition, note

signs of infestation. Record treatment usedto date, plus that of family members andcontacts.

It is vital to have a clear assessment of

skin recorded so that comparativejudgments can be made. Signs of burrowswill indicate scabies is still present, ratherthan a residual pruritis, which may last for2-3 weeks. Knowing previous treatments isimportant, as a maximum of weeklytreatments for 3 weeks should not beexceeded. Also some scabicides arethought to be more effective.


It is vital to work with the patient andnegotiate achievable goals for treatment;the patients physical ability andunderstanding, external commitments and

motivation need to be taken into account. Itis useful to ascertain if external help will beneeded to follow treatment through e.g.district nurse, home help or health visitor.Agreed treatment protocols are essential innursing practice, thus ensuring uniformityand good standards of care; additionally asa formal record they act as a referenceguide when considering accountability.


The belief is held that patients will follow aparticular route through treatment andachieve common or core objectives;acknowledging that patients haveindividual needs, these pathways will bealtered accordingly. It is vital that atreatment regimen facilitates patienteducation to enable an understanding ofwhat scabies is and how it can beeffectively treated. (See table 3).Approaching core goals in this wayencourages uniformity and maintenance ofcare standards in a formal way.


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Appendix GRationale for treatment and management of scabies

Action Rationale.Treat with Malathion or Permethrinfollowing guidelines strictly.

There are three treatments available:Quellada M (aqueous Malathion 0.5%)Derbac M (aqueous Malathion 0.5%)Lyclear Dermal Cream (Permethrin 5%)Derbac M is the only one suitable for

pregnant women. Permethrin is thought tobe the most effective, and therefore maybe the treatment of choice. (11)Guidelinesand the rationale behind them are set outin table 3.

Repeat initial treatment after 10 days. For effective treatment as eggs may havebeen untreated on initial treatment.

In crusted scabies follow extra precautions In crusted scabies there are thousands ofmites, so transmission is easier and it maybe difficult to treat. (See table 4).

Be meticulous in the tracing of contacts. Poor clearance or retransmission ofscabies is often due to failure to treat allclose contacts.

Instigate the use of emollients, topicalsteroids and antihistamines.

To maintain skin integrity and reducepruritis.


Action RationaleReview patients at 7 10 days after initialvisit/treatment.

To assess efficacy of treatment.Observe for signs of infestation stillpresent. Provide support andencouragement that clearance will beachieved and pruritis will subside.To provide a forum for patient education.

Assess and record skins appearance ateach visit. To record response to treatment, look forclinical signs of scabies, to monitorresidual pruritis and observe for potentialsecondary infection.For clear record keeping and showingawareness of personal accountability.

Verbally assess if family members orcontacts have had a good response totreatment.

To assess the level of clearance and to beaware of the potential of retransmission.(See table 3)


The aim of the treatment plan is to givepatients the confidence to treat themselvesat home and manage their own skincondition. Being an effective resource can

facilitate this process.Reducing frequency of visits as skinimproves, guiding patients throughdecision making and making use of thetreatments they have available





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6.0

Treatment and management ofhand and foot eczema. (Adult)

Holistic assessment and history taken. Skinassessed, extent of affected


.Treatment regimenplanned with patientfollowing agreedprotocols. Incorporatingthe core plan of care.

Presentationof condition.

First line treatment.Review at 4-8 weeks

Second line treatment, tobe started if poor responsenoted by week 4 -8.

Dry, scalingthickened andcracking.

Use a potent/ verypotent topical steroid inan ointment base.Use cotton gloves whenable or tubifast to feet.Advocate greasymoisturisers if tolerated,see Table 1.

Treat cracks with eithersuper glue to cleancracks or hydrocolloiddressing.

Try polythene occlusion withemollient and topical steroidfor 1week max. Thenreassess, consider tryingalternative potent topicalsteroid.Be cautious about occlusion ifthere are numerous cracks,

which have potential localinfection. Consider Haelantape to cracks

Hyperkeratoticor lichenified.

Use potent topicalsteroid and advocategreasy moisturisers(table 1). Try localocclusion withhydrocolloid or pastebandages.

Consider keratolytics underpolythene occlusion tohyperkeratotic areas.Lichenified areas may beslow to respond so continuewith initial treatments.

Weepy,

pruritic orpompholyxappearance.

Use KMnO4 as

compress (see advicesheet). Use potenttopical steroid in creamform, considercombination with an antibacterial, see table 2.Use cotton gloves and atolerated emollient.

Try modified wet wraps or

paraffin dressings asappropriate. Recommend oralantihistamines particularly atnight time. Observe for signsof secondary infection.

Core plan of care.This follows initialassessment and is aplanned teachingprogram theimplementation of thisprovides support andguidance, enabling the

patient to understandhis/her condition andrecognize the mosteffective treatments.The educative programwill emphasize theimportance of avoidingastringent substancessuch as soaps andshampoos.Soap substitutes arerecommended, inaddition to an oiladditive to bath/wash

water. Skin should bemoisturised at least 2/3times daily or wheneverskin is dry All topicalsteroid applicationsshould be used inconjunction withemollients. See table 1.for further details.

Acutelyerythematousand pruritic.

Use potent topical/verypotent steroid, cottongloves and a toleratedemollient. Creams maybe more cooling.

Recommendantihistamines andelevation.

Consider polytheneocclusion.

In hand eczema advice re: avoidance of irritants is vital, it is also important to identify if this is potentially acontact dermatitis, in which case patch testing would be beneficial.Moderate clearance should be noted by 8 10 weeks. If yes continue and modify treatment for dischargearound week 12-14. If not then referral to Secondary care may be required; this also remains an option if theskin flares at any time.Refer to Appendix I for the rationale behind treatment protocols, methods of patient review and dischargeplanning. Refer to Appendix J for teaching plan.


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6.1 Appendix IRationale for the treatment and management of hand and foot eczema


other health problems and certainmedication. Also there can be a greatpsychological and social impact of thedisease. Environmental factors such as

regular contact with certain substancesmay be relevant.

Extent of eczema and present treatmentsrecorded.



It is vital to work with the patient andnegotiate achievable goals for treatment,

the patients physical ability, andunderstanding, external commitments andmotivation need to be taken onto account.Agreed treatment protocols are vital innursing practice, thus ensuring uniformityand good standards of care; additionally asa formal record they act as a referenceguide when considering accountability.


The belief is held that patients will follow aparticular route through treatment andachieve common or core objectives;acknowledging that patients haveindividual needs, these pathways will be

altered accordingly. It is vital that atreatment regimen facilitates patienteducation to enable understanding of theircondition and the most effective treatment.Approaching core goals in this wayencourages uniformity and maintenance ofcare standards in a formal way.


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Appendix IRationale for the treatment and management of hand and foot eczema

Action RationaleAdvise to use of soap substitutes andemollients.

Soaps and shampoos are astringent andcan dry the skin. Advocating an effectiveskin care regimen using emollients is theessence of eczema management.Washing with an emollient is a moisturizing

and cleansing experience.

The cleansingaction removes dead skin cells andresidual topical medicaments.Emollients act to reduce loss of skinmoisture and help restore the lipid barrierimbalance. For the emollient to work as aneffective barrier it must be reapplied atleast 2-3 times daily, 4-5 times if possible.The range of emollients is wide and variedso the patient needs to be clearly advisedso that they can make an informed choiceof the one which suits them and their skin.

Patient education is aimed at enabling the

patient to understand his/her skin conditionand recognize the most effectivetreatments.

Patients need a clear understanding of

their skin condition in order to comprehendthe benefits of certain treatments. Tonesand Tilford link patient education withpatient satisfaction, which in turn promptsa change in behaviour. This of course isvery relevant to the extent to which thepatient will comply with the treatmentprotocol suggested to them. In addition, ifpatients are to recognize the benefits oftheir potential treatments, they mustunderstand their actions and possible sideeffects. E.g. correct application of topicalsteroids can minimize potential side

effects.All topical steroid applications should beused in conjunction with emollients. Wherepossible tubifast coverings or cotton glovesare recommended.

Using a combination of topical steroids andemollients works very effectively for thetreatment of eczema. Topical steroids aremore rapidly absorbed when applied towell moisturised skin. The ideal is to applythe moisturiser 20 minutes prior to steroidapplication. Tubifast coverings/cottongloves hold creams and ointments inplace, providing mild occlusion and canprevent the individual harming their skin ifthey scratch.

Using topical steroids in the treatment ofeczema.

Topical steroids suppress varioussystematic components of theinflammatory reaction. Topical steroids canbe combined with antibacterial andantifungal agents. Vehicle choice can beimportant, for instance cream can becooling on a hot erythematous skin.


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Action RationalePotent topical steroids are used and theirprogress and usage are monitoredcarefully.

Palms and soles have a thick epidermis,which may reduce percutaneousabsorption of topical steroid. Potent topicalsteroids can be used in these areas, oftenfor longer periods than elsewhere. It is

important to regularly review a patientusing a potent topical steroid, so that asskin improves a step down to a moderatethen mild potency steroid can be made tolimit the long - term side effects, howeverwith correct usage, these side effects canbe kept to a minimum.

Patient education should include thecorrect usage of topical steroids.

Generally people are concerned aboutusing topical steroids. It is important toallay these fears with some clear facts andguidelines that can be followed.Reassuring the patient about these issuescan improve patient compliance and

ensure correct usage. Although overusecan be a problem so can under use. It isbetter that the correct quantities are usedfor a shorter length of time, than too littlesteroid over a long length of time withfrequent flares.

Treat cracks with super glue or duodermextra thin.

The cracks on hands and feet can be verypainful and have the potential for localinfection. A clean split or crack can besealed with superglue, thus reducing painand regaining skin integrity. Duoderm is ahydrocolloid and provides an idealenvironment for wound healing as well as

the provision of a comfortable waterproofprotection for multiple cracks. Haelan tapeis a waterproof tape impregnated with apotent topical steroid and can be used tocracks,12 out of 24 hours.

Using paste bandages. These are helpful in the management ofexcoriated, inflamed and lichenifiedeczema. They are occlusive and offersimilar benefits to the wet wraps. There area variety of paste bandages available; thechoice depends on skin presentation andpatient tolerance.

Using polythene occlusion to hands andfeet.

Occlusion concentrates the effects of themoisturiser and topical steroid, byimproving percutaneous absorption. It isalso a useful way of softening areas ofhyperkeratosis.

Using potassium permanganate (KMN04)to weepy areas.

This is an astringent oxidizer, which isused for its cleansing/antiseptic effects andfor its drying effects on weepy skin. It canbe an irritant and care must be taken todilute it and use correctly.


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Action RationaleUsing wet wraps or paraffin gauzedressings.

Often used to control itch scratch cycle.They are not suitable for infected eczema.They involve applying a warm, moisttubifast covering over skin treated withemollient and a mild topical steroid. This

creates a cooling effect throughevaporation, rehydration via emollients,protection from scratching, allowingexcoriations to heal and improved steroidabsorption. If there are multiple raw areasthen multilayered paraffin gauze may berequired to provide comfort and allowhealing to occur.

Recommending oral antihistamines. These can be useful short term to relievepruritis and may help to break an itchscratch cycle, particularly if scratching isoccurring in the sleep. Depending onchoice they can have a sedative effect.

Observe for signs of secondary infection. There are many topical agents availablethat have antimicrobial properties. Thesemay be useful in the management oflocalized infection, however if there isgeneralized infection then systemicantibiotics may be necessary. A moist skinswab should be taken to clarify antibioticsensitivity.It is vital to be aware of the potential ofviral and fungal infections. (See table 6).

Using occlusion to thicker lichenified areas. Occlusion concentrates the effects of themoisturiser and topical steroid. It is auseful way of softening areas of

hyperkeratosis.


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Action Rationale.Review patients regularly whilstundergoing treatment.

To assess efficacy of treatment.Provide support and encouragement clearance may take 12 weeks or more, if

morale is poor, compliance may alsosuffer.To provide a forum for patient education.

Assess and record the skins appearanceat each visit.

To monitor the response to treatment andto make modifications to treatment plan tomeet changing patient needs.Observe inflammation, weeping or othersigns of infection.For clear record keeping and showingawareness of personal accountability.


The aim of the treatment plan is to givepatients the confidence to treat themselvesat home and manage their own skin

condition. Being an effective resource canfacilitate this process.






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7.0 TABLE 1Emollients This includes some of the commonly used emollients,however there are others available.

Criteria for choice Emollients listed from light creams to greasy ointmentsAqueous cream- use as soap substitute onlyE45 cream*Ultrabase

Aveeno cream

Easily applied, well tolerated.Contain preservatives, so observefor sensitivity to these. Creams

have a high water content so canbe cooling on hot erythematousskin.

Cetraban.

Diprobase cream*Oilatum cream*- now available in junior formulationUnguentum M. *

Greasier creams providing aneffective barrier for moisture loss.Easily applied and well tolerated.

Neutrogena dermatological cream.Epaderm* PThicker base, but still water soluble,

so can be used as soap substitute.Not so easy to apply, but offerseffective barrier without a wet/oilyfeel.

Emulsifying ointment* P

Emollin 50/50 PDiprobase ointment. P

Ointment base, easy to apply. Mayneed coverings as leave skingreasy. Ideal for very dry andhyperkeratotic areas. Can beocclusive, causing a hotuncomfortable feeling and maycause folliculitis.

White soft paraffin/liquid paraffin 50/50. P

The asterick denotes emollients suitable for use as a soap substitute. This can also be used as amoisturiser unless a lighter or greasier moisturiser is preferred. As a general rule the drier theskin the greasier the moisturiser.

Patients using large amounts of emollient group containing paraffin (denoted by P)should be advised regarding the associated fire risk and provided with the National

Patient Safety Agency advice leaflet found at the end of these guidelines.Emollients with specific properties

Antibacterial- Dermol 500 lotion* and dermol cream* useful in infected/excoriated eczema andMRSA.

Containing urea, a hydrating agent, useful for scaly conditions. May cause stinging. - Aquadrate,Calmurid or Eucerin. Balneum Plus contains urea & lauromacrogols that have a local antipruriticaction.Bath OilsDermol 600 Bath EmollientEmulsiderm Emollient also useful for descaling hyperkeratosis on scalp.Oilatum Frangrance Free Bath OilBalneum (soya oil) and Balneum Plus Bath Oil- (anti-pruritic)

Reviewed 21.12.2007Review due 21.12.2008


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7.1 TABLE2Topical Steroids Potencies

Mild Moderate Potent Very potentHydrocortisone 1%(HC)

Betamethasonevalerate 0.025%(Betnovate RD)

Betamethasonevalerate 0.1%(Betnovate)

Clobetasol propionate0.05% (Dermovate)

HC 1% + urea 10%(Calmurid HC)

Clobetasonebutyrate 0.05%

(Eumovate)

Betamethasonedipropionate 0.05%

+ salicylic acid 3%(Diprosalic)

Clobetasol propionate0.05% + neomycin

sulphate 0.5% + nystatin100000 units/g(Dermovate NN)

HC 0.25% +crotamiton 10%(Eurax HC)

Clobetasonebutyrate 0.05% +oxytetracycline 3%+nystatin100000unitsper/g (Trimovate)

Flucinoloneacetonide 0.025%(Synalar)

HC 0.5% & Coal tarextract 5% (AlphosylHC)

Desoximethasone0.05% (Stiedex LP)

Fluocinonide 0.05%(Metosyn)

HC 1% +oxytetracycline 3%(Terra-Cortril)

Mometasone furoate0.1% (Elocon)

HC 1% + miconazolenitrate 2%(Daktacort)

Betamethasonevalerate 0.1% +fusidic acid %(Fucibet)

HC 1% + fusidic acid2% (Fucidin H)

Hydrocortisonebutyrate 0.1%+chlorquaninaldol3% (Locoid C)


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8.0 Application of Emollients (moisturisers) Advice Sheet forprofessionals/patients/carers

8.1 Apply directly to the skin.

8.2 Always apply in a downward motion in the direction of the hair growth.

8.3 Avoid vigorous rubbing which may cause plugging of the hair follicle and theninfection.

8.4 Always apply after a bath/ shower.

8.5 Do not stop once the condition is controlled. Emollients will help to prevent futureexacerbations.

8.6 Apply moisturisers as frequently as possible but at least 2-3 times daily.

8.7 Always try to reapply moisturiser to hands after they have been in contact withwater.

8.8 Apply the moisturiser in amounts that will cover the skin thoroughly and if you havetime, allow them to soak in naturally.

8.9 If you feel the moisturiser you are using does not suit you, please contact me andwe can alter it sooner rather than later. Remember, a good moisturiser is onewhich you will use frequently!!!

Val AndersonDermatology Nurse

South Gloucestershire PCT


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9.0 Audit Tool

These guidelines will be evaluates through the number of annual referrals fromprimary care health professionals to the dermatology nurse service.

In addition the usefulness of these guidelines will be audited via annualquestionnaires to be distributed to HVs, PNs and DNs within South Gloucestershireby the Dermatology Nurse.

10.0 Equality Impact assessment these guidelines should not impact on anyminority or vulnerable groups

11.0 References

British National Formulary (2007) Section 13.5.2.

Chaffman, M (1999) Topical Corticosteriods : A review of Properties and Principles inTherapeutic use. Nurse Practitioner Forum (10) 2 pp 95-105.

Cooper, P; Clark, M; Bale, S (2007) Best Practice Statement: Care of the OlderPersons Skin.

Ersser, S; Maguire, S; Nicol, N; Penzer, R; Peters, J (2007) A Best PracticeStatement for Emollient Therapy Dermatological Nursing Vol 6; Issue 3.

Griffiths, C E and H L Richards Psychological Influences in Psoriasis. Clinical andExperiment Dermatology 2001.26: pp 338-342.

Hobden, A (2006) Strategies to promote concordance within consultations. BritishJournal of Community Nursing, 11(7) 286-289.

Hughes, E and Van Onselen, J (2001) Dermatology Nursing, a Practical GuideEdinburgh. Churchill Livingstone Press.

Lee, M; Marks, R (1998) The role of Corticosteroids in dermatology AustralianPrescriber (21) 1.

Richard, C. The Effects of Psoriasis and its Treatment: part 1. Nursing Times, 1995.91(4) : pp 38-39.

Richards, H L, et al, Patients with psoriasis and their compliance with medication.Journal of Amercian Academic Dermatology, 1999. 41(4) : pp 581-583.

NICE Guidelines : Management of Childhood Atopic Eczema.

12.0 Bibliography

Buchanan P and Courtenay M (2006) Prescribing in Dermatology Cambridge.Cambridge University Press.

Ashton, R and Leppard, B (2005) Differential Diagnosis in Dermatology Oxon,Radcliffe Publishing Ltd.

Kennedy, C and Mitchell, T (206) Your Questions Answered: Common SkinDisorders London. Churchill Livingstone.

13 0 National Patient Safety Agency Fire Hazard leaflet

dermatology treatment guidelines

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