Safe steroid cream use; how to make up and mix your own blended steroid cream for your eczema, or for your child, for better and longer-lasting results. Although I blend steroid prescription drugs and a base cream, you can do this yourself if you have been given the prescribed cream, and they are unopened.

Why make your own blended cream?

Your GP or primary care physician will always prescribe creams for your child’s eczema. There are usually three types.

These start with simple moisturiser, the first cream, which doctors like to call emollients. At their most basic this is an oil, some distilled water, and something to make them mix together and stay in an emulsion or cream without separating. More expensive emollients have additional ingredients and stabilisers.

When the skin is more inflamed, he will prescribe a second type, a steroid cream. Always starting with the weakest, and as your child gets older or the eczema more severe, progressing to moderate or stronger steroid creams. These are really cortico-steroids creams; our most effective anti-inflammatory agent on the skin. These are NOT related to “steroids” that body-builders use, which are based on testosterone.

Later, when the child’s skin is very inflamed, a third cream is used. Particularly if there has been bleeding and spreading eczema, he will say it is very likely infected, and your child can have an antibiotic cream to use, for a week against a germ called Staph aureus. Sometimes there will be pustules, sometimes not. Mostly your GP won’t bother to take a skin swab, but just tell you he knows it is staph. Skin swabs are seldom taken, since we know the primary germ is usually staph. UK guidelines state that skin swabs are not helpful.

If you tell your GP the moisturiser isn’t working, he/she may give you an alternative one to try, although his NHS permitted range is limited, and some really are better than others. The NHS range is limited. You may yourself buy something more effective. You will notice the more effective emollient creams often have a plant-based ingredient in them – either wheat germ, or shea butter, or coconut oil, but there are many plant-derived oils good for skin healing. Aveeno for example, has wheat germ oil, and is extremely popular in the UK. I like to add one of these; Argan oil, Shea butter, or Coconut oil. I also like to use Vaseline for its water-proofing properties, but in small amounts.

Now there are a few combination creams prescribed on the NHS, with antibiotics and steroids, although not many. You may have had a prescription of one of these, the commonest being Fucidin-H (with weaker steroid, Hydrocortisone) or Fucibet (the combination of Fucidin with Betnovate, which is moderate strength steroid).

For the most part, when I was a doctor working on the NHS, and prescribing tubes or tubs of these creams, I would try and persuade patients to use both the moisturiser and the steroid together, but I knew that they often would not. They would use one on one occasion, and a different cream on a different occasion. Usually stopping the steroid rather too soon. I developed the habit of saying they could spread a finger-tip unit of the prescribed steroid creams, first one, then another if also using an antibiotic, and finally a third – the emollient. They all thought I was crazy. This would be a 1 in 3 dilution of the steroid on the skin. Perhaps I was crazy too, but that is the guideline advice, and finger-tip units are all the rage in dosing of steroids on the NHS. Finger-tip units help doctors prescribe steroids safely. But it is the dilution that really works best. One always needs much more emollient than anything else.

Now that I have retired from the NHS, I pre-mix all the elements together that I know work, because they are all needed for different purposes, and I want my patients to use all three of the main ingredients. The emollient is essential to help bind the surface skin cells together and help repair the skin barrier. The problem here is that the cells on the surface are dead, and flattened. They need a kind of glue to seal them together and fats to allow the skin to be supple and waterproof. Some people produce too little of the binding matrix agent, called fillagrin (filament aggregating protein), and others have too little of the oils (Ceramides) so their dry itchy skin simply gets scratched too thin in places to repel germs. This dry skin is very susceptible to eczema, as germs like Staph easily get through, and moisture easily escapes.

Once inside the skin, Staph releases toxins, delta toxins in the main, but also others. These toxins attract histamine and white blood cells, and the immune response. The skin itches intolerably. Staph is very good at overcoming our immune system response. This means it is able to establish bacterial colonies on the skin, and it does like warm damp areas, so the armpits, the elbow flexures, behind the knees, the neck, and the hands, are all favourite spots. In fact sweaty areas tend to smell, because they grow numerous different germs, and the fats or oils our bodies produce goes rancid if not washed regularly. The more severe the eczema, the more that staph is a problem, and eradication takes quite some time. This requires antibiotics, or the bleach baths that dermatologists are fond of. Steroids are needed to reduce the inflammation, and antibiotics to eradicate the Staph. This, with emollient makes three elements to mix together.

 

The fourth element is something very waterproof, or a natural element, since the cream itself may not be enough to properly waterproof the skin. Trans-epidermal water loss is extremely common in eczema, and worsens the state of health of the skin, A greasier stiffer oil in the mixture also helps. So, the fourth element is usually white soft paraffin – Vaseline is a make that is well known. You can also use a natural product like coconut oil, or shea butter instead. I always add a fifth ingredient, a little argan oil, a natural product that has excellent properties for repairing the skin. One should avoid perfumed products, but many vitamin E oils are ok to add, provided you try a little first on normal skin, to ensure you don’t react.

If your GP has prescribed tubes of steroid cream, these will usually be 1% Hydrocortisone or Betamethasone/ Betnovate. The antibiotic will usually be Fucidin or Mupirocin. The tubes invariably come in 30g sizes, your emollient may be anything he chooses, and often just aqueous cream. Mupirocin is more expensive, but has the advantage of being used very rarely, and therefore there is almost no Staph-resistance to it. Additionally, Mupirocin is an ointment, so it is easier to see when it is well mixed with a cream. Here are all the ingredients assembled to make up 300g of blended cream:

 

1% Hydrocortisone is usually used with younger children, and on the face, and Betnovate (Betamethasone) more commonly for older children, and never on the face. However, the blending process is the same whichever steroid or antibiotic you have been given.

The main reason for doing the blend or dilution, is that the skin requires all these components to effectively treat the eczema. Leave one ingredient out, and it will not work nearly as effectively. Use them together, and you get a result that far exceeds your expectations. When treating an acute flare, with very inflamed skin, it is usually made with a greater amount of steroid and antibiotic, so a whole tube or 30g. This would require using 30g steroid, 30g antibiotic and 30g Vaseline in 150g of emollient cream. It is 1/8 dilution, as there is 1 part steroid in the finished quantity 240g of cream.

Once the flare has subsided and the skin starts to look normal, the doses of the steroids, and antibiotics can be halved to 15 g of each, 15 g of Vaseline, and 150g emollient. A weaker dilution is enough to prevent eczema flares when the skin is quiet, but the immune system will still over-react for some time, if the skin is scratched. If you are using neat steroid tubes on your skin, your dermatologist would be advising using this cream neat, once or twice a week to prevent flares. It can take several months for eczema to subside in this manner, much longer than you might expect. So using it at least once daily in a much weaker dilution, makes sense.

Furthermore, it can take a year or so to increase healthy bacteria in the gut by changing your child’s diet to affect the microbiome in the gut, and therefore the immune system. A whole year or two of having live probiotic yoghurts, or yoghurt drinks, or Kefir, and a year of introducing more green vegetables, and different fruit. A more diverse gut microbiome makes for a much healthier immune system, and less likelihood of any severe reactions or inflammation in the skin, in the air passages of the lungs, or in response to food proteins that may be unusual.

How to make your own blended cream:

The procedure outlined below will make a 1 in 10 dilution cream, and although it may not be exact if you estimate measures, it will still be safe to use. If you were using a doctor’s prescribed diluted betnovate for example, this is almost always a 1 in 4 dilution – Betnovate RD. This method is therefore less than half a strong.

 

I am giving you instructions on how to mix your own creams, and it should always start with washing your hands, and assembling all your ingredients together on a clean surface, and with a very smooth non-plastic surface, like a glass surface. Using a palette knife, mixing your own creams, always mash the creams together starting with the Vaseline, antibiotic and steroid, so that you don’t see any more flecks of greasy Vaseline in the cream, and try and mix these small ingredients well together, before mixing in equal small amounts with larger quantities of the base emollient cream.

Use your palette knife to fill the pots or jars which keep the cream. All items should have been thoroughly cleaned with alcohol gel first, and air dried, or given a wipe with a clean piece of kitchen towel. Avoid touching your creams, and the inside of jars.

This you tube clip shows how one should do the mixing; pay attention to the first half, and ignore the second half of this clip, which shows the mixed cream put onto greaseproof paper and then inserted into a tube