Eczema Full

SCHOOL OF PHARMACEUTICAL SCIENCES UNIVERSITI SAINS MALAYSIA

FAR 454/3

TOPIC TITLE (5): ECZEMA (GROUP 8) GROUP MEMBER:NUR SYAWAZAH KAMARUZZAMAN (90381) NURBAIZURAH MOHD ALI (90382) NURUL LIYANA SAMSUDDIN (90383) NURULAIN NADIAH ALIAS (90384) OI AUN CHYI (90385) ONG POH HOOI (90386) ONG SU LING (90387) ONG ZHI YING (90388) OOH WEI HON (90389) OOI CHAH CHAH (90390) OOI KEAN LOON (90391) OU YEN PENG (90392) SAKUNTHALA A/P JAYABALAN (90393) LECTURER: Dr. Chong 1. What are the signs and symptoms of eczema? The signs and symptoms of eczema this patient experienced are redness of the skin, raised vesicles on chest, neck and face, and some weeping lesion with pus on the chest and neck Generally, signs and symptoms of eczema are: •

Patches of chronically itchy, dry, thickened skin usually on the hands, neck, face, legs and other affected area of the body.

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Redness, scaling and changes in skin colour.

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Small bumps or blisters which ooze fluid.

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The skin may show inflammation and may produce scales that infection may result.

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Clinically, reactions may be acute, chronic, delayed or commulative.

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Strong irritant-acute, wet work-chronic, some chemicals-delayed.

2. What are product selection guidelines for management of eczema? Eczema requires a management plan, including identification and avoidance of xternal triggers, maintenance of skin patency, use and several therapeutic options for symptomatic relief. Therapy should be individualized, and a multiple approach should be initiated. Reduction of symptoms, prevention of recurrent flares, and modification of the course of the disease is the best long term strategy for managing eczema.

3. State and rationalize the pharmacological regimen and non-pharmacological management for eczema. a) Non-pharmacological treatment

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Identify and eliminate potential allergens

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Reduce frequency of bathing; bathe every other day

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Use of tepid water in baths

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Avoidance of irritating soaps (dyes, fragrances, and preservatives can all contribute to further exacerbations)

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Avoid washcloths or irritating scrubs

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Air dry skin and gently pat dry

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Application of emollient (preferably an ointment or cream, again watching for dyes, fragrances, and preservatives) within 3 minutes after bathing

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Keep fingernails short and clean to prevent scratching

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Consider cotton gloves to prevent scratching at night

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Use of cotton sheets and pajamas

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Avoid harsh laundry detergents (some may contain allergens)

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Moisturize as often as necessary to keep skin soft and pliable (at least twice a day)

Given that patients with eczema are more susceptible to irritants than normal individuals, possible aggravating factors that may trigger a flare-up should be identified. Recommendations can include avoiding extraneous perfumed or dyed soaps and detergents, using a second rinse cycle for laundry, avoiding extremes of temperature fluctuations, and otherwise being cognizant of potential allergens. Sunscreens should be used in patients with eczema, but judicious use of nonchemical agents (e.g., physical sunscreens such as titanium or zinc oxide products) are probably less likely to cause further irritation or contact dermatitis. The epidermis of atopic skin has a reduced capability of holding moisture. This inherently dry skin is also exacerbated by external changes, including variations in weather and allergen exposures. Thus the importance of maintaining proper skin patency cannot be overstressed, as slight irritations to atopic skin can result in microfissures, which act as portals of entry for various pathogens. b) Pharmacological treatment •

Topical corticosteroid

- Topical corticosteroids have been the standard approach for treating the inflammation and pruritus of eczema. Typically used in short-term reactive treatment of acute flare-ups, topical corticosteroids must be supplemented with emollients. - Most corticosteroids are applied once to twice daily. Should the steroid be used in conjunction with other topical agents, including moisturizers, the corticosteroid should be applied first, rubbed in well, and followed by the other product. A good rule of thumb is that approximately 30 g of cream or ointment can cover the average sized adult once. Thus if treatment needs to be twice daily to the entire body for 2 weeks, the average adult will go through 2 pounds of topical corticosteroid. •

Anti-histamine - Antihistamines are used to attempt to break the itch-scratch cycle that results from the pruritus of eczema. - Because pruritus is worse at night, the sedating antihistamines (i.e., hydroxyzine or diphenhydramine) can offer an advantage by facilitating sleep. - One tricyclic antidepressant, doxepin, inhibits both H1 and H2 receptors, and it has been used for treating adults with eczema in doses of 10 to 75mg at night and up to 75mg twice daily

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Topical Immunomodulators

- Topical calcineurin inhibitors, including tacrolimus and pimecrolimus, have added a new dimension to treatment of AD. Unlike corticosteroids, these agents offer a more long-term option, as they can be used on all parts of the body for prolonged periods without fear of corticosteroid-induced adverse effects. These agents form a complex that results in inhibition of calcineurin, which normally initiates T-cell activation. i.

Tacrolimus (Protopic) 0.1% ointment: for moderate to severe AD in adults not responding adequately to other therapies

ii. Tacrolimus 0.03% ointment: for moderate to severe AD in

children over 2 years old iii. Pimecrolimus (Elidel) 1% cream: for mild to moderate AD in

children and adults (it has been studied in infants as young as 3 months)

○ Applied twice daily ○ May be used for longer term ○ Can result in reduction in flare-ups •

Tar preparations

- Coal tar preparations reduce itching and inflammation of the skin. These products have been used in combination with topical corticosteroids, as adjuncts so that lower strengths of corticosteroid can be used effectively, and in conjunction with ultraviolet light therapies. These preparations are available as crude coal tar (1% to 3%), or liquor carbonis detergens (5% to 20%). 4. Provide counseling information regarding the use of topical corticosteroid and other pharmacological agents for management of eczema. 1) Topical corticosteroid Most commonly, the highest- potency steroids are used for short periods of time (generally less than 3 weeks) for acute flare-ups of eczema or for lichenified (thickened) lesions. Because of their potential adverse effects, these steroids should not be used on the face, mucous membranes, eyelids, or skin fold areas. The potential for adverse effects of topical corticosteroids depends a variety of factors. The concentration applied, the amount applied, how often it is applied, and for how long it is applied can be important factors to consider. Long-term topical corticosteroid use primarily results in cutaneous abnormalities such as skin atrophy, striae, hypopigmentation, and steroid-induced acne. Moderate-strength steroids may be used for more chronic eczema, typically on the trunk or extremities. Low-potency steroids are usually used in children. •

Potency of the steroid depends upon the vasoconstrictive properties ➢ Typically, with high-potency steroids

➢ Use no longer than 3 weeks ➢ Use on thickened lesions ➢ Not for use on face, skinfolds, or mucous membranes

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The vehicle is as important as the steroid concentration ➢ Occlusives can increase percutaneous absorption ➢ Ointments are stronger than creams, which are stronger than lotions

➢ Gels may be beneficial for hairy or oily areas •

Use with moisturizers ➢ Apply corticosteroid first ➢ The goal is to increase moisturizers while decreasing corticosteroid use

2) Anti-histamine •

Certain anti-histamine such as diphenhydramine can cause sedative effect. Advise the patient for not driving or operating a machine after taking this medication.

• 3) Topical Immunomodulators •

The most common patient complaints with topical tacrolimus therapy are transient itching and burning at the site of application. Although no data support the practice, many clinicians recommend pretreatment with topical corticosteroids to prevent or reduce tacrolimus-induced burning and erythema.

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Patients who receive long-term systemic immunosuppressants are prone to developing actinic keratoses, viral warts, and nonmelanoma skin cancers. Although there are no such reports from topical use, the judicious use of adequate sun protection should be stressed in patients receiving topical tacrolimus for eczema.

4) Tar preparations •

Coal tar preparations should not be used on acute oozing lesions, as this would result in stinging and irritation. The strong odor of coal tar products and their staining of clothing are limiting factors. Patients can be instructed to use the product at bedtime and wash it off in the morning.

REFERENCES: 1. Joseph T. Dipiro et al., Pharmacotherapy: A Phatophysiologic Approach, 6th ed., Elsevier, London.