Question 1

Jaya is using elocon steroid for 2 stubborn patches on hand. Would she benefit from using a different steroid? Is there something new?

Answer

I think the situation you are describing is one I come across quite frequently in the clinic - a treatment works well and clears most areas, but some stubborn patches remain, which never clear up completely. This seems to be particularly common on the hands. Obviously, I am unable to comment on Jaya’s situation without more details, but in general terms, there are several choices about how to deal with this:

1.Your comment about using a different steroid is a good one, because there is some evidence that the body gets used to steroid creams after a while, and that it can be helpful to change to a different steroid. I would suggest a steroid of at least an equivalent strength, e.g. Betamethasone ointment; or consider a stronger steroid eg. Clobetasol ointment, if your dermatologist feels it is safe.

2.Add some bandages over the elocon. Bandages will make the elocon more effective. I often use bandages called ‘ichthopaste bandages’ in this situation, because they also contain icthammol which is a type of tar known to soothe and improve eczema. Ichthopaste bandages are soaked in ichthammol so they are wet when you put them on. A secondary dry bandage is put over the top, and the whole lot can be left on for 2-3 days. A specialist nurse needs to show you how to put the bandages on for the first time, but after this most parents can put them on at home.

3.You could consider changing to a different active treatment which is not a steroid. There are 2 new treatments licensed for eczema which can be used when steroids are not working – pimecrolimus (Elidel) cream and tacrolimus (Protopic) ointment. Both are a type of drug called ‘immunomodulators’ – see more below. Patients should be assessed by a doctor with a special interest in skin problems before they start using an immunomodulator.

Question 2

Please can you tell me what the difference is between corticosteroids and immunomodulators and when you should use them?

Answer

Corticosteroids and immunomodulators are both effective treatments for atopic eczema. Corticosteroids have been widely used to treat eczema for over 40 years, so we know a lot about how we should use them, and what side effects they can cause. There are many different corticosteroid preparations. They can be divided into 4 Potencies (strengths), according to their chemical structure.

These are:

Mild e.g. Hydrocortisone

Moderate e.g. Clobetasone (eumovate)

Potent e.g. Mometasone (elocon)

Very potent e.g. Clobetasol (dermovate)

Corticosteroids are first line active treatment for atopic eczema, if red angry patches persist despite using a regular moisturiser. Your doctor will advice which steroids are the right ones for your child. This depends on where the eczema is, and how bad it is. Corticosteroids are very safe if they are used in short bursts for flares of eczema. Occasionally, they can cause side effects such as thinning of the skin if used for long periods in delicate areas e.g. around the eyes. This will also depend on the potency of the product as well as where they are applied.

Immunomodulators are much newer drugs- tacrolimus was developed as an immunosuppressive agent to prevent organ transplant rejection, and has been developed into an ointment available in 0.03% and 0.1% strengths. Tacrolimus 0.1% ointment has been shown to be as effective as a potent steroid at treating eczema. Pimecrolimus cream is a milder immunomodulator which works as well as hydrocortisone.

Immunomodulators are recommended as second line active treatment for eczema in children over 2 years if corticosteroids are not working, or are at risk of causing side effects. The reason immunomodulators are not used first line is because we don’t know whether they can cause side effects long term. As they act on the immune cells in the skin we advise being careful in the sun to minimise the risk of skin cancer and applying them at night with sun protection in the morning. Sometimes they can cause stinging when first applied to the skin but currently the evidence suggests they are safe.