Example eczema treatment plans

Phase 1 is treatment of the acute flare and requires a flare blend of cream for 2-4 weeks. Aron type formula of dilute steroid, antibacterial and moisturiser.

Phase 2 is interval treatment and requires a much weaker dilution of steroid to prevent flare, and moisturiser. In this phase we also introduce pro-biotic healthy germs into the gut, and improved nutrition to repair the gut microbiome which controls our immune response to many proteins and germs.

Phase 3 is a moisturiser with added ceramides and bio-active natural oils to complete the repair of the skin. In this phase we ensure that patients are able to stick with skin care and nutrition over time to prevent further cascade into other allergic disease.

While no treatment plan can ever be described as one size fits all, it is possible to categorize eczema according to the age of the patient, the area affected, how long the eczema has lasted, and how long flares have previously taken to settle.

After initial assessment, plans will normally fall into the acute flare treatment stage, then in the same season, prevention of further flare, followed by on-going repair and maintenance over the same year. Different cream dilutions and components are required for each stage. It may be necessary to repeat the flare stage if this recurs the same year.

Example treatment for younger children

So for example, let us take the case of a four or five year old child, who started having episodes of eczema in the first year of life, initially on the cheeks, and then neck, and in the second or third year of life the backs of the knees, and then the front of the elbows and wrists. Despite plenty of emollient creams, and interval applications of 1% hydrocortisone cream during flares, the parents suspect that the eczema is “getting worse”, and the child is becoming resistant to the steroid creams used. There may be reasons for the flares, such as a fever or a cold, a reaction to a new food, or a change in the season or weather, or a new fabric jumper blamed. There is often frustration at how an apparently insignificant event has lead to a flare lasting some time.

For this four or five year old child, I might begin treatment with a premixed flare cream containing a more potent steroid than 1% hydrocortisone if this has already been used with minimal effect, but in a weaker dilution, so probably a 1 in 8 betnovate dilution, with added 1 in 8 dilution mupirocin antibiotic, so that applications can be started 4 times a day for the first week, and then three times a day for the second week, followed by twice a week for the third week. By day 21 the eczema appearance will be minimal, or clear. With less severe eczema the clearance may be much more rapid. The applications then taper according to response, to smaller amounts of cream applied less often.

By week four the cream components may be changed to a premixed prevention, so that the steroid may be diluted further to 1 in 12 , and the antibacterial to 1 in 12 to prevent a further flare in the same season. When the season changes, the cream will generally change to the skin barrier repair components, which must continue for some time. These components should include ceramide, bio oil, and emollients, with shea butter added to improve the consistency. These ingredients improve the skin health, and have been shown to repair damage to the skin, but take time.

Treating severe eczema in younger children

With more severe, or more widespread eczema, or for those with a longer history, one might expect that more potent steroid creams might already have been prescribed previously. Such higher potency steroid creams carry a higher incidence of side effects or unwanted changes to the skin, so that doctors now avoid using more potent steroids in children and remain cautious in adults. Children with severe incapacitating eczema are more commonly treated with wet wrapping to retain the steroid for longer contact and better absorption into the skin. However wet wraps or bandaging is both time-consuming, and difficult to do well outside of hospital or specialist supervision settings.

However, using a blended cream approach, with a higher dilution of steroid allows for frequent application of the cream, again four times a day, or even five times initially, without wet wraps, to gain the same advantages, and control of even quite severe eczema may be gained by this approach, given a slightly longer time-frame.

Treating older children with eczema

So a treatment plan for an older child, with more widespread or severe eczema may simply take a little longer. What we know from scientific studies and from clinical experience is that during more severe flares, there is much greater concentration of Staph aureus, much greater release of histamine and allergic or immune response under the skin, and a march or cascade to further allergic-type diseases such as asthma, and food allergies. The release of greater amounts of toxins from staph beneath the skin accompanies greater immune responses both within the skin, and more generally, so that there may be more severe reactions to various foreign proteins or germ.

The treatment plan here will include a slightly higher concentration of antibiotic in the pre-mixed cream, and there may need to be a slightly higher concentration of steroid initially, but the dilution is not very different, since greater amounts of emollient are also needed, and larger quantities of cream will be applied overall.

Formulating a blended cream for your specific condition

What is critical with planning the treatment cream dilutions is a knowledge of how much steroid, antibiotic, and emollient cream is required to treat this particular flare, based on the age, and surface area of the body affected, and a knowledge of the quantities of each that are generally required to treat these and for how long. Palm of the hand sizes are generally used as units of measure, since a ratio to total body size can be easily estimated, and one can readily calculate doses and quantities of cream required per week for such areas.

In my experience it is common to find that patients have stopped using emollients as the child seems to recover, or used very little, not being aware that the barrier function of previously at risk skin takes quite some time to repair properly. They may have discontinued steroid creams too early, not being aware that once or twice weekly applications are required in order to prevent the next flare. Commonly we find fears or misconceptions or misunderstanding about the condition. Whole review articles and chapters have been written on myths surrounding eczema.

The role of probiotics and pre-biotics in treating eczema

It is also extremely common to find that parents have been given little or inadequate advice on the role of pro-biotics, such as live yoghurts in the first four years of life to prevent eczema worsening, by introducing healthy bacteria into the child’s gut to train the immune system properly.

I have seldom found patients with a proper understanding of pre-biotics, the food fibre required to encourage healthy bacteria to populate the gut in a properly diverse microbiome, and in any event, the science of genomic DNA mapping of the bacteria in the microbiome of the gut can be carried out and the analysis used to monitor how well the diet has changed this during phase 2 and 3.

Therefore in treatment plans with families where there is a known predisposition to more severe eczema, and cascade into asthma and food allergies, it is essential to have plans which include longer duration of flare cream use, longer duration of maintenance cream, and more diligent application of pro-biotic prevention, and dietary management to ensure adequate pre-biotic and consequent change in the microbiome of the gut.

The more severe the eczema problem is, the more likely patients over time, will have encountered the different disciplines of general practice, dermatology, immunology, allergy testing, microbiology, and soon I would predict, also genetic testing, dietetics, and microbiome analysis. As atopic march cascades into asthma and food allergies, and chronic eczema, it is inevitable that patients and doctors should ask, can this be prevented, and how?

The answer is that we don’t know everything, but we know enough to do better.

Please contact me to learn more about my methods, or request an appointment if you are ready for a consultation.

Eczema treatment plan