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Latest guidelines emphasise the rationale and strategic approach for continuous emollient care

General practitioners and consultant dermatologists are now able to draw upon best-practice guidelines for continuous emollient  care in eczema and dry skin management. The guidelines, which are  published today (6th September 2002) in the peer-review Journal of Dermatological Treatment, have been developed by a multidisciplinary group of dermatology specialists, in collaboration with the National Eczema Society. The guidelines, “Advised best practice for emollient use in eczema and other dry skin conditions”,[1] propose a rationale and strategy for improving skin disease, thereby increasing positive clinical outcomes for patients. 

Whilst there is, as yet, little clinical evidence from randomised, controlled trials to demonstrate the efficacy of emollients,[2] it is clear that they are effective in maintaining the skin’s lipid barrier via their action of forming a protective, oily barrier over the skin’s outer surface (stratum corneum).[3] The advised best-practice guidelines highlight the necessity of communicating to 
healthcare professionals – and in turn to their patients – the message that effective eczema and dry skin management rests on the regular and continuous application of emollients.

General Practitioner Dr Stephen Kownacki, one of the paper’s authors and Chairman of the Primary Care Dermatology Society, illustrates the fundamentals of emollient therapy: “Emollients are a valuable management resource in reducing and treating eczematous conditions, but the real key is to understand that patients predisposed to eczema need to apply sufficient amounts and to use them continuously – and that also includes during periods when the eczema is controlled.” 

The key recommendations for best-practice management in continuous emollient care are as follows. 

1. All health professionals involved in the care of patients with eczema and dry skin conditions should understand the basic principles of emollient use.

2. Patients with eczema and other dry skin conditions should avoid soap and use an emollient soap substitute when washing, bathing and showering.

3. A daily emollient routine is an important part of the management of patients with eczema and other dry skin conditions even when the skin is under control. Emollients should be applied at least twice daily so it is important that they are supplied in adequate quantities (up to 500 g or more per week).

4. It is important that patients understand the relative benefits of steroid creams (to reduce inflammation) and emollients (to combat dry skin).

Eczema accounts for approximately 30% of general practice dermatology consultations,[4] but improvements in patient/carer education in terms of the management of their condition could see 
a reduction in the 15–20% of school children and 2–3% of adults[5] (around one third of all community cases[2]) affected by eczema. Dr John English, Consultant Dermatologist and one of the authors of 
the guidelines, observes that, “Despite current, and not least the emergence of new and forthcoming, therapies for eczema, there will always remain the need for dermatology physicians to follow, and 
for their patients to apply, basic skincare principles to help control inflammation whilst introducing prescribed treatments.” 

The rationale for developing these guidelines is born of the need to address inadequate dermatology training at primary care levels, as well as the diversity in dermatology service provisions, and 
further of the need to improve the disparity in its management. These inequalities in dermatology services are detailed in the Dermatological Care Working Group report,[6] which also concluded 
that ‘expert patients’ who become ‘sharers in their care’ are best placed to improve their self-management via their understanding of their condition and the appropriate use of its treatment. 

The National Eczema Society also identifies the need to increase the level of service and knowledge of eczema and associated skin conditions. Sue Ward, Educational Manager at the National Eczema 
Society feels that, “As with any chronic condition, people living with eczema, and their families, need ongoing support from their healthcare professional in order to improve the understanding and 
outcomes of their condition. We welcome initiatives and recommendations that complement our work in striving to improve the quality of life for all those affected by eczema.”

The ABC Programme and principles
As a follow-up to their recommendations, the authors established the ABC Programme with further support from the National Eczema Society and accreditation from the British Skin Foundation. The 
ABC Programme is an educational initiative aimed at improving healthcare professionals’ understanding of the need to adopt basic skincare principles, whilst in turn enabling them to discuss and agree these principles with their patients. 

As a follow-up to the paper, “Advised best practice for emollient use in eczema and other dry skin conditions”,[1] published today (6th September 2002) in the Journal of Dermatological Treatment,1 its 
authors have established the ABC Programme, with the support of the National Eczema Society and accreditation from the British Skin Foundation. The ABC Programme is an educational initiative 
aimed at improving healthcare professionals’ understanding of the need to adopt basic skincare principles, whilst in turn enabling them to discuss and agree these principles with their patients. 

The ABC Programme is based upon a practical, three-step strategy that easily fits into a patient’s (or carer’s) daily skincare routine: 

A: Avoid soap
* Patients with eczema and other dry skin conditions should use an emollient soap substitute when washing, bathing or showering

B: Benefit from emollients
* A daily emollient routine is an important part of the management of patients with eczema and dry skin conditions, even when the skin is under control. Emollients should be applied at least twice daily, so it is important that they are supplied in adequate quantities (up to 500 g or more per week) 

C: Control inflammation
* It is important that patients – and carers – understand the benefits of steroid cream (to reduce inflammation) and emollients (to combat dry skin)

Emollients and prescribed treatments that control inflammation are key components of eczema management. Of equal importance is the need to remove all soap products from the washing regimen of patients affected by eczema.[2] However, a recent survey by the National Eczema Society[3] demonstrates that whilst many respondents acknowledge that soap exacerbates their condition, more than one in three continue to use it, leading to timely and costly referrals. Whilst over 90% of respondents had been prescribed emollients to help treat flare-ups, only 26% had received a 
demonstration of how to apply them; that equates to almost three-quarters who received no practical demonstration on the application of emollients. 

References
1   Holden C, English J, Hoare C et al. Advised best practice for the use of emollients in eczema and other dry skin conditions. J Dermatol Treat 2002; 13(3): 103–6.
2    Hoare C, Li Wan Po A, Williams H. Systematic review of treatments for atopic ezcema. Health Technology Assessment 2000; 4: 37. 
3   Cork MJ. Taking the itch out of eczema: how the careful use of emollients can break the itch-scratch cycle of atopic eczema. Asthma J 1999; 4: 116–20.
4   McHenry PM, Williams HC, Bingham EA. Management of atopic eczema. BMJ 1995; 310: 843–7.
5   Charman C on behalf of Clinical Evidence. Atopic eczema. Br Med J 1999; 318: 1600–4. 
6   Dermatological Care Working Group. Assessment of best practice for dermatology services in primary care. London: Ash Communications; April 2001.*

* The DCWG report is available in PDF format for downloading at www.skincarecampaign.org

* The authors of the best-practice recommendations for emollient 
therapy are: 
- Dr Colin Holden, Consultant Dermatologist, St Helier Hospital, Carshalton, Surrey
- Dr John English, Consultant Dermatologist, Queen’s Medical Centre University Hospital, Nottingham
- Ms Colette Hoare, Information Office, National Eczema Society, London (now left the Society)
- Dr Andy Jordan, GP, Water Meadow Surgery, Buckinghamshire 
- Dr Stephen Kownacki, GP, Albany House Medical Centre, Northamptonshire and Hospital Practitioner in Dermatology at 
Northampton General Hospital. Dr Kownacki is also Chairman of the Primary Care Dermatology Society, a specialist interest group for UK general practitioners affiliated to the British Association of Dermatologists 
- Sister Rosemary Turnbull, Clinical Nurse Specialist in Paediatric Dermatology, Chelsea & Westminster Hospital, London
- Dr Richard C D Staughton, Consultant Dermatologist, The Lister Hospital, London