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NICE guidance on use of topical corticosteroids in atopic eczema.

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Atopic eczema is a common chronic relapsing inflammatory skin condition that can have a significant impact on quality of life. Atopic eczema has both acute and chronic phases. Table 1 shows the clinical features of these.


VOL: 100, ISSUE: 38, PAGE NO: 26

Kathy Radley, BSc, RGN, is clinical nurse specialist in dermatology, Pilgrim Hospital, Boston, UK

Atopic eczema is a common chronic relapsing inflammatory skin condition that can have a significant impact on quality of life. Atopic eczema has both acute and chronic phases. Table 1 shows the clinical features of these.



Atopic eczema is usually diagnosed clinically based on the appearance of the skin as well as patient and family history. The most common features are described in Table 1. Most patients have widespread dry skin, and secondary infection is common, especially in children.



Topical corticosteroids are the main treatment for atopic eczema. They are safe and effective if used appropriately, and patient education and support is a significant factor in their success. The National Institute for Clinical Excellence (2004) has just issued guidance relating to the frequency of application of topical corticosteroids in atopic eczema, recommending that they should be prescribed for application no more than twice a day, and that where more than one preparation is clinically appropriate, the cheapest should be prescribed.



Table 2 shows the treatments available for patients with atopic eczema. Management of the condition is complex, and often involves a lengthy and complicated treatment regimen, of which topical corticosteroids may be a part.



Newer treatments such as topical immunomodulators (tacrolimus and pimecrolimus) have recently been licensed for use in atopic eczema.



Topical corticosteroids



Topical corticosteroids are one of the main treatment options for atopic eczema. When used appropriately they can provide a safe strategy for management, but patient education is crucial to concordance. Potential side-effects include thinning of the skin, worsening of untreated infection, irreversible striae and contact dermatitis.



A useful practical guide to the amount of steroid to apply is the fingertip unit (Long and Finlay, 1991). The FTU is the length of an adult index finger to the first joint. Using a standard (5mm) nozzle tube, one FTU equals 0.5g cream/ointment. Long and Finlay give guidelines on the amount for application to different areas of the body. For example, an adult arm requires 1.5g (three FTUs).



Patients are often anxious regarding the use of topical corticosteroids. One study found nearly three-quarters of patients using topical corticosteroids admitted being worried about using them (Charman et al, 2000). Education for their appropriate use enables patients to make informed choices regarding their treatment.



Topical corticosteroids are classified into four groups by potency - mild, moderate, potent and very potent - and are available in a range of preparations. A general rule of thumb is to use ointments on dry skin and creams on wet or weepy areas. Scalp preparations are also available.



NICE guidance



The guidance issued by NICE concerns the frequency of application of topical corticosteroids, and addresses the use of preparations containing steroids only, rather than other active ingredients such as salicylic acid or antibiotics. It concerns cost and efficacy in comparing the same preparation applied once daily with more frequent applications, and once-daily preparations with preparations licensed for twice-daily or more applications.



The appraisal committee considered evidence from a systematic review, randomised controlled trials (RCTs), manufacturers/sponsors, clinical experts, patients/carers and professional groups. Some studies were acknowledged to be of poor quality, and all compared only short-term effects (of no more than four weeks). One of the RCTs showed statistical difference between regimens when assessed by physicians, but this was not supported by the patient’s assessments.



When the cost of once-daily preparations is compared with those marketed for twice or more daily applications, the committee concluded the once-daily regimen proves more costly than other generic or proprietary products used twice daily. Taking account of who pays for the products and the way they are used, savings to the NHS may be £300,000-£600,000 (excluding VAT) for a patient group of 100,000 with atopic eczema. However, information is not available on current prescribing patterns.



In considering expert opinion, the committee acknowledged that frequency of application is not a big issue for most patients with atopic eczema as they are applying emollients regularly throughout the day. Quality patient education is a significant factor in the success of therapy, and the continuing education of health care professionals is important for them to provide the correct advice.



The committee concluded that there is no compelling evidence of a clinically statistical difference between once-daily and more frequent applications of topical corticosteroids in terms of their effectiveness, patient satisfaction, adverse events, concordance with therapy or number of follow-up visits required.



It also concluded that where more than one alternative topical corticosteroid is considered clinically appropriate within a potency class, the product with the lowest acquisition cost (taking into account pack size and frequency of application) should be used.



Recommendations for further research are made, covering further comparisons of preparations, long-term follow-up for adverse effects and issues for patients, regarding quality of life, support and education.



Implementation of this guidance will involve clinicians reviewing current practice and policies. Local guidelines and care pathways should incorporate this guidance. Audit will determine compliance by practitioners and the appropriateness of prescribing for atopic eczema.



Related guidance comparing the clinical and cost-effectiveness of tacrolimus and pimecrolimus has also been published by NICE.



Implications for nursing practice
Obvious implications for practice relate to independent nurse prescribers who are part of the group of clinicians required to implement the guidance. Many nurses, including supplementary prescribers, will be involved in discussions to formulate local guidelines and care pathways.



The implications are wider than this, and affect many nurses who care for and support patients with atopic eczema using topical corticosteroids and those considering their use. It is no coincidence that education and support of patients is highlighted in the document, and much of this is done by nurses working in a variety of care settings at many different levels. There is pressure on dermatologists and other doctors to meet targets, and nurses are well placed to provide support and practical advice for patients on effective application of treatments (Gradwell et al, 2002).



Nurses are in an ideal position to spend time with patients, facilitating them to make informed decisions about their treatment. Support for health care professionals regarding education is essential, and groups such as the British Dermatological Nursing Group are doing much to promote provision and access of education in dermatology at both local and national levels.



NICE has issued guidance (Box 1) regarding the frequency of application of topical corticosteroids for patients with atopic eczema. Its implications affect all nurses who have contact with patients experiencing this common condition, especially regarding perceived success and concordance. Areas highlighted for further research include quality-of-life issues and support for patients, which are key areas of nursing practice.



The British Dermatological Nursing Group can be contacted at: 4 Fitzroy Square, London, W1T 6EH.



This article has been double-blind peer-reviewed.

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