Posts Tagged ‘irritant’

triamcinolone A glucocorticosteroid with the actions, uses and side-effects of hydrocortisone, but differing by promoting sodium excretion, and so is of no value in adrenal cortex deficiency states. It is used in a wide range of inflammatory, allergic and respiratory states, and in inflammatory skin conditions.
Dose: 8-24 mg daily. It is also given as triamcinolone acetonide in doses of 40 ing by deep i.m. injection for a depot action. The acetonide is also given by iniraarticular injection in doses of 2.5-40 mg in local inflammation of the joints, and by intra-lesional injection in doses of 2-3 mg at any one site for the treatment of skin lesions. Triamcinolone actonide is also used as a 1% cream or ointment in severe inflammatory skin conditions. The side-effects are those of the corticosteroids (see hydrocortisone), but triamcinolone may also cause myopathy with high dose treatment. (Kenalog; Ledercort).
triamterene A potassium sparing diuretic, used mainly in association with more powerful drugs. It is indicated in oedematous conditions generally, and, as it causes some retention of potassium, its use avoids the need for supplementary potassium therapy.
Dose: 150-250 mg daily, with lower doses for the elderly and when given in association with other diuretics. Rash .ind gastrointestinal disturbances are ,ide-effects. (Dytac). See page 148 and Kahle 21.
tribavarin An inhibitor of viral replication used in severe viral bronchiolitis in infants.
Dose: by aerosol inhalation of a solution (20 ing/ml) for 12-18 hours daily liar 3-7 days, together with supportive therapy. (Viravid).
triclofos A derivative of chloral, with the sedative properties of the parent drug, but less irritant to the gastric mucosa.
Dose: I 2gdaily.
alternative to penicillamine in other conditions. The main side-effect is nausea.
trifluoperazine A powerful tranquillizing drug of the chlorpromazine type. It is used mainly in schizophrenia and similar psychoses, and in severe anxiety.
Dose: 10-20 nig or more daily according to need. In severe anxiety, 2-6 ing daily. In acute conditions, 1-3 mg daily by deep i.m. injection. As an antiemetic, it is given in doses of 2-4 mg or 1-3 ing by injection. The side-effects are similar to those of chlorpromazine, including extra-pyramidal symptoms, but the anticholinergic and sedative side-effects are less severe. (Stelayine). See page 168 and Table 30.
tri-iodothyronine See liothyronine.
trilostane An inhibitor of enzyme systems concerned with production of mineraloand glucocorticosteroids by the adrenal cortex, and so resembles metyrapone to some extent. It is used to control adrenal cortex hyperfunction and the excessive production of aldosterone.
Dose: 240 ing daily initially, adjusted tip to a maximum of 480 mg daily, according to the plasma corticosteroid levels. Care is necessary in liver and kidney dysfunction. (Modrenal).
trimeprazine A sedative antihistamine used in the treatment of pruritus and allergic itching conditions, and for premedication.
Dose: 30-100nig daily; pre-medication dose: 3 mg/kg. (Vallergan).
trimetaphan A short-acting ganglionic-blocking agent. It is used to produce a controllable reduction in blood pressure (luring neuro- and vascular surgery when a relatively bloodless field is necessary. Dose: by i.v. infusion, 3-4 nighnin initially, with subsequent doses carefully adjusted to the response. Side-effects are tachycardia and respiratory depression. Frequent determination of blood pressure during use is essential.
triclosan A chlorinated phenolic antiseptic, used mainly in surgical scrubs and similar preparations. (Manusept; Ster-Zac).
trientine A copper-chelating agent used in Wilson’s disease, but only for patients unable to tolerate penicillamine.
Dose: 1.2 -2.4 g daily. It is not an
trimethoprim An antibacterial agent similar in action to the sulphonamides. It is used in the prophylaxis and treatment of urinary tract and respiratory infections due to sensitive bacteria.
Dose: in chronic infections, 200-400 nig daily; prophylactic dose, 100mg daily. In severe infections, 130-250 mg twice daily by slow i.v. injection. Side-effects are nausea, vomiting,rash and pruritus, and possible bone marrow depression. (lpral;
Monotrim). See co-trimoxaole.
trimetrexateV An antibacterial agent used like atovaquone in AIDS patients with Pnettinocystis carinii pneumonia.
Dose: 45 ing/nidaily by i.v. infusion for 21 (lays, followed by calcium folinate 80 nighty daily for 28 days, orally or i.v. (Neutrexin).
I Tyr
oral antidiabetic drugs by increasing the sensitivity to endogenous insulin, and so acts as an insulin enhancer.
Dose: 200 mg daily with breakfast, increased if required by 200 mg at intervals of 2-4 weeks up to 600 mg daily. Side-effects are diarrhoea, fatigue and malaise. (Romozin). See page 131 and Table 13.
tropicamide A short-acting mydriatic agent similar to homatropine. Used as 0.5% and I% solution.
trimipramine A sedative anti-depressant with the action and side-effects of amitriptyline. It is valuable in depression complicated by anxiety.
Dose: 75-300 mg daily. (Surmontil).
triple vaccine Diphtheria, tetanus and pertussis vaccine for the primary ininitinization ofchildren.
Dose: 0.5 ml by i.m. or deep s.c. injection.
triptorelin A synthetic form of gonadorelin, used in the treatment of advanced prostatic cancer. Such cancers are testosterone-dependent, and triptorelin acts by depressing pituitary function, and so indirectly reduces the plasma level of testosterone.
Dose: It has been formulated so that a single i.m. injection of 4.2 ing depresses testosterone production for 28 days. Initially there may be a temporary flare-up of symptoms, which can be prevented by giving an anti-androgen for 3 days before treatment, and continued for 2-3 weeks. Patients should be monitored for uleric obstruction and spinal cord compression during the first months of treatment. DecapepivI Sr). See page 122.
tropisetron A 5–HT.,-receptor antagonist, similar to ondansetron bill with a longer action. It is used to control the nausea and vomiting induced by cancer chemotherapy.
Dose: initially as a 5 mg dose i.v. shortly before such therapy, and followed 1)), oral doses of 5 mg daily, I hour before food, for 5 days. Side-effects are dizziness, headache and gastrointestinal disturbance. (Navoban). See page 122.
tryparsamide Used in late trypansomiasis when the CNS is involved.
Dose: 1-3 g by injection weekly, up to a maximum Lill) of 24 g. May damage optic nerves.
tryptophan\7 An amino acid involved in the biosynthesis of serotonin. It is used in specialist centres for the treatment of severe and prolonged depression resistant to other drugs, and where a deficiency of serotonin may be a factor. (Optimax). See page 128 and Table 11.
tuberculin A product obtained from cultures of Mycobacterium tuberculosis. It is used in the diagnosis of tuberculosis. See BGC vaccine.
103
trisodium edetate A chelating or binding agent that is sometimes used in hypercalcaernia. The calcium complex so formed is excreted in the urine.
Dose: slow i.v. infusion tip to 70 rng1kg daily according to need and response, as shown by plasma calcium measurement. It is also used as a 0.4% solution for
ophthalmic use in lime burns of the eyes. Side-effects after injection are nausea, diarrhoea and cramp. Contraindicated in renal impairment. (Limclair).
troglitazone A new drug for non-insulin dependent diabetes. It differs from other
tulobuterol A selective beta,-adrenergic agonist of the salbutamol type, used in the prophylaxis and treatment of bronchospasm in asthma and related conditions. Dose: 4-6 mg daily. (Respacal). See page 118 and’fable 6.
tyrothricin A minor antibiotic used as
lozenges for mouth infections.

undecenoic acid An organic acid with useful antimycotic properties. It is used mainly as powder or ointment (5%), often with zinc undecenoate in the treatment of athlete’s foot and associated conditions.
urea An osmotic diuretic. It has been used orally in doses of 5-15 g. Applied locally as a 10% solution, it promotes granulation and reduces odour front•    foul ulcers.
urofollitrophin A preparation of human lollide-stimulating hormone (FSH) used with nienotrophin for the induction of ovulation. Dose and duration of treatment require careful control to avoid Over-stimulation. (Metrodin; Orgafol).
I Vas
allergen vaccines, used for desensitization to various allergens such as grass pollens, arc not true vaccines, but weak solutions of allergen extracts. They may precipitate allergic reactions in susceptible patients, and should be used only when emergency resuscitation measures are immediately available.
valaciclovirV A pro-drug of acyclovir used in herpes zoster. It is well absorbed orally, and quickly converted to the parent drug and promotes an improved response.
Dose: 3 g daily for 7 days, reduce([ in severe renal impairment. Dose in herpes simplex I g daily. Side-effects are headache and nausea. (Valtrcx). See page 144 and Table 19.
valproic acid (Convulex). See sodium valproate.
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urokinase A plasmin activator obtained from human urine. It is used mainly in the thrombolysis of blocked i.v. shunts, and in the lysis of blood clots in the eye. Dose: 5000-37 500 units, instilled into the shunt; similar doses are injected into the anterior chamber of the eye for the resolution ofl)l blood clots. (Ukidan).
ursodeoxycholic acid The acid appears to be a solvent of cholesterol, and is given orally to promote the dissolution of cholesterol-containing gall stones.
Dose: 8-12 mg/kg as a single daily dose, hut prolonged treatment is required, which should be continued after the dissolution of the stones to inhibit recurrence. The dissolution of calcium-containing or radio-opaque stones is unlikely to occur. (Destolit; Ursofalk).
valsartan An angiotensin II receptor antagonist used in hypertension. It has a more selective action than the ACE-inhibitors. Dose: 80 mg daily. Combined treatment with a potassium-sparing diuretic is not advisable. (Diovan). See page 148 and Table 21.
vancomycin An antibiotic used in severe antibiotic-associated staphylococcal colitis ( pseudomembranous colitis).
Dose: 0.5 g daily for i-10 days. It is also given by injection in resistant bacterial endocarditis; I g twice a day by slow i.v. infusion over 1-2 hours, as rapid injection may cause anaphylactic shock. Blood concentrations of the antibiotic should be monitored, as the many side-effects include renal damage, ototoxicity and ncutropenia. Pruritus and upper body flushing may occur, and tinnitus is an indication that the drug should be withdrawn. (Vancocin).
vaccines Bacterial vaccines are suspensions or extracts of dead bacteria, but sonic anti-viral vaccines are also available. They may be given by s.c. or i.m. injection, and are used mainly for prophylaxis against a particular infection. The most commonly used vaccines include those for typhoid, cholera, diphtheria, influenza, tetanus and polio. Protection against mumps, measles, pertussis, rubella, yellow fever and hepatitis can also be obtained. The so-called
vasoconstrictors Drugs such as noradrenaline that constrict the peripheral vessels, and so cause a temporary rise in blood pressure. They are useful in hypotensive conditions when the blood volume is still adequate, and in controlling the fall in blood pressure that occurs in spinal and general anaesthesia.

A-Z Principal Drugs (ACTH - Allopurinol )

ACTH See corticotrophin.

actinomycin D
A cytotoxic antibiotic, also known as dactinomycin, that inhibits cell division by forming a stable complex with DNA. It is used mainly in Wilm’s tumour, and tumours of the
uterus and testes.
Dose: 500 pg daily for 5 days by i.v. infusion, but other dosage schemes are in use. It is highly irritant to soft tissues, and great care must be taken to avoid extravasation.
Close haematological control is necessary. Skin eruptions, alopecia and gastrointestinal disturbances are frequent side-effects. Cosmogen). ‘,cc page 122 and Table 8.

aciclovir (aciclovir)
An antiviral agent highly active against herpes simplex and zoster viruses. It acts indirectly by inhibiting the DNA polymerase essential for viral replication.
Dose: 200 mg 5 times a day for 5 (lays in herpes simplex infections of the skin and mucous membranes, and in genital herpes; in shingles (herpes zoster), 800 mg orally 5 times a
day for 7 days is given, but treatment should be started as soon as possible to obtain the maximum relief of pain. A 5% cream is used for superficial infections, and for herpes
simplex keratitis a 3% ophthalmic ointment is available. Acyclovir is also of’great value in herpes simplex infections in immunocompromised patients. Dose: 200 mg 4 times a day:
800 mg 5 times a day in zoster infections. In severe conditions, 5 mg/kg or more 8-hourly by i.v. infusion. It is also given orally for longterm prophylaxis in such patients.
Reduced doses are necessary in renal impairment and in the elderly. Side-effects include gastrointestinal disturbances, rash and neurological reactions. (Zovirax). See page 144
and Table 19.

adapaleneV
A new retinoid used like tretinoin in the treatment of acne. Applied as a 0.1% gel, once a day, taking care to avoid all mucous surfaces. Irritation may require temporary
withdrawal. (Differin gel).

adenosine
A cardiac drug that slows conduction through the AV node. It is used to restore normal sinus rhythm in paroxysmal tachycardia.
Dose: given by rapid i.v. injection as an initial dose of 3 mg. A second dose of  may be necessary after 1-2 minutes, and a third dose of 12 mg if the tachycardia
remains uncontrolled. For use only with close cardiac monitoring. (Adenocor).

adrenaline (epinephrine)
Adrenaline is one of the principal hormones of the medulla of the adrenal gland, but is now made synthetically. It acts on both the alpha and beta receptors of the sympathetic
nervous system. The effects of the alpha receptors result in vasoconstriction with a rise in blood pressure; stimulation of the beta receptors increases cardiac rate and output,
and relaxes bronchial muscles. Dose: in cardiac arrest, 0.2-0.5 nil of 1 1000 solution by sac. or i.m. injection. In anaphylactic shock and allergic emergencies, 0.5-1 mg (0.5-1
nil of 1:1000 solution) is given by i.m. injection and repeated every 15 minutes as required. An i.v. injection of an antihistamine is sometimes given as supportive therapy.
Doses of 100-200 Vg ( 1-2 nil of 1:10000 solution) have been given by intracardiac injection in cardiac arrest and syncope. In hypotensive crises, noradrenaline or meetaraminol
are preferred. Adrenaline is added to local anaesthetic solutions (1:50000-1:200000) to prolong the anaesthetic effect by reducing diffusion of the anaesthetic solution.
Occasionally the solution is applied locally to stop capillary bleeding and epistaxis. it is also used as eye drops (I I%) in chronic open angle glaucoma, but may cause redness
and smarting of the eye. Solutions of adrenaline may darken on storage and lose activity.

albendazole
An anthelmintic used in hydatid disease with larval cysts of the dog tapeworm. The cysts do not develop into worms, but increase in size to simulate liver abscess.
Dose: given as an adjunct to surgery in doses of 800 mg daily for 28 clays, repeated after a 2-week rest period for 3 cycles, with liver tests and blood counts. (Eskazole).
albumin (human) Human albumin, obtained from pooled human plasma. Given by i.v. infusion as a 5-20% solution in the treatment of shock and other conditions where restoration of
blood volume is urgent; in severe burns to prevent haemoconcentration, and in some conditions of
oalbumaemia, and in acute oedema.

alclometasone

A highly potent topical cortikosteroid. It is used as a 0.05% cream or ointment in inflammatory and pruritic dermatoses likely to respond to such    about 90 seconds after i.v.

alcohol (ethanol)
Used occasionally by injection to destroy nerve tissue in (he treatment of intractable trigeminal neuralgia. Industrial alcohol or methylated spirit contains 5% of wood naphtha;
surgical spirit is industrial alcohol with the addition of methyl salicylate and other substances and is used for skin preparation and the prevention of pressure sores.
Ordinary, coloured, methylated spirit contains pyridine, and is not suitable for medical purposes.

aldesleukin
A recombinant form of interleukin-2, a lymphokinine that stimulates the production of interferon and T-Iymphocytes. Used in metastatic renal cell
carcinoma; severe toxicity is common. (Proleukin).

aldosterone
The main mineralocorticoid hormone of the adrenal cortex. An excessive secretion of aldosterone may occur in some oedematous states and reduce the action of thiazide diuretics.
See spironolactone and canrenoate.

alendronate
A bisphosphonate used in postmenopausal osteoporosis. It inhibits osteoclast activity and increases bone strength, but continuous treatment is necessary. Dose: 10 mg daily in
the morning with water on an empty stomach, 30 minutes before food. Side-effects include severe oesophageal reactions. (Fosomax).

alfacalcidol
A derivative of calciferol, with a more powerful and rapid action. It is used to treat hypocalcaemia in hypoparathyroidism, neonatal hypocalcaemia and other hypocalcaemic
states, and in vitamin D-resistant conditions. Regular blood calcium determinations are
essential as a drug-induced hypercalcaemia percalcaemia may take weeks to subside after
withdrawal.
Dose: 1 mg orally or i.v. daily initially, according to response. (,Alpha 1); OneAlphal.

alfentanil
A potent, rapidly acting narcotic analgesic, useful in short surgical procedures, or for longer operations in ventilated patients. The peak effect occurs

alfuzosin

A selective alpha-adrenoceptor blocking agent for the symptomatic treatment of benign prostatic hypertrophy (BPH).Dose: a first dose of 2.5 mg should be given in bed to avoid a marked first-dose hypotensive response, then 7.5 mg daily. Side-effects are dizziness, hypotension and
tachycardia. (Xatral). See page 164 and Table 28.

alglucerase

An enzyme product used i.v. by specialists in Gaucher’s disease. (Ceredase).

alkylating agents
Cytotoxic drugs which act by damaging DNA, and so interfere with cell replication. Chlorambucil and cyclophosphamide are examples.

allantonin
A natural substance said to promote wound healing. Present in some locally applied products for skin disorders.

allergen vaccines
Weak allergen vaccines prepared from allergens such as grass pollens, house dust mites and bee stings are used to desensitize hypersensitive individuals but such treatment
carries the risk of severe anaphylactic reactions, which may prove fatal in asthmatics, and it is now recommended that desensitization therapy should be carried out only when
full cardiorespiratory resuscitation
measures are immediately available.

allopurinol

An enzyme inhibitor that blocks the formation of uric acid, and so is useful in the treatment of chronic gout. It also reduces the formation of uric acid calculi. It is usefulin the hyperuricaemia of leukaemia but it should be given before cytotoxic therapy is commenced.Dose: 100 mg daily as a single dose with food, slowly increased to 300 mg daily or more as required, reduced in cases of renal impairment. It may cause gouty arthritisinitially, requiring colchicine or non-steroidal anti-inflammatory agent (NSAID) treatment for at least I month. Side-effects include nausea, headache and gastrointestinal
disturbances, but skin reactions indicate withdrawal of the drug. (Zyloric). See page 140 and Table 17.

Many countries have special schools for children with severe asthma and other allergies. Italian children are sent to one in the Italian Alps, where there is no trace of pollen, house-dust mite, or animal allergens. After nine months these children are a great deal healthier and more active - all their lung function tests are vastly improved. Blood tests show that they are actually less allergic to common allergens than before.
You may not be able to do quite this well at home, but all allergens and irritants can be avoided to some extent. Even if you can’t eliminate them completely, you can certainly reduce your exposure.
Before you start, it is important to be clear about exactly what affects you, otherwise you will be wasting a lot of effort. For example, people who are allergic to dust mite often think that a dusty house will necessarily be worse for them than an apparently clean house, but this is not so (see p. 115). Or they may say ‘Oh, I got asthma on holiday, because the roads were so dusty and I’m allergic to dust,’ forgetting that only house dust contains dust mites. The road dust may have acted as an irritant, and helped to spark the asthma attacks, or it may have contained pollen or mould spores - but it does not contain dust mites or their allergens. Blaming the wrong thing for the asthma attack means that the real culprit is not identified.
If you are not absolutely sure what causes your allergies, skin-prick tests (see p. 91) can identify the allergen. These are especially recommended if your reactions to the presumed allergen are inconsistent, or you don’t respond to the anti-allergen programmes described here. For example, a few people who react to house dust are not allergic to dust mites, but to something else in the dust such as wool fibres or mould spores, or particles from cockroaches, house
flies, carpet beetles or a long-departed cat. Even pollen that has accumulated in house dust can provoke allergic reactions - if you are not an over-keen duster, it can still be there long after the pollen season.
If you have hayfever, knowing which pollens cause your symptoms (and learning to recognise the plants concerned) is useful. You will probably need skin-prick tests to be sure. ‘Hayfever’ can even be a seasonal mould allergy in some people (see p. 27).
Tackling allergens is now big business. There are a lot of people out there competing for your money and false claims are common, especially for anti-mite products. Only a few manufacturers are deliberately misleading, and most false claims probably stem from ignorance or wishful thinking, but be very sure you know the facts about your allergen before you buy.
Air cleaners are a good example. A really good quality air cleaner (which uses a HEPA filter - a High Efficiency Particulate Air filter) is an expensive purchase and, as the advertising tells you, it takes out very small particles with staggering efficiency. But this is entirely irrelevant if the source of those particles is no distance at all from your nose - your mite-infested pillow, for example, or the cat on your lap.
Something else that advertisements for air cleaners rarely mention is that unless you reduce allergen production - tackling mould growth in the house, for example, or keeping the dog outside - the filter can’t help much. In short, air cleaners do have their uses for some allergens, but they can’t work miracles.
The products mentioned here, if not available in your locality, can be bought mail-order from specialist suppliers of anti-allergy products (see p. 255). Note that some offer both very good products and distinctly doubtful products, so judge each item on its individual merits. Ask to see scientific evidence that it works.
Don’t be taken in by vague statements such as anti-allergenic’ - get the facts. This label is often used on pillows with synthetic filling, for example, and people assume that it refers to dust-mite allergy, whereas it simply means that the pillow does not contain feathers. But unless you are allergic to feathers, there is no reason to avoid feather pillows. (In fact, if not covered with mite-proof covers, synthetic pillows collect more dust-mites than feather pillows, because the fabric used for the cover is less tightly woven and the mites and skin particles get in more easily.)
Bad advice is also a hazard. Some of it just wastes your time and effort, but some could actually increase your exposure to the allergen. Advice to vacuum floors daily, or to vacuum beds, is commonplace but this achieves little and it means breathing much more allergen unless you have the right kind of vacuum cleaner. One health magazine even advised its readers with dust-mite allergy to ‘air mattresses by regularly turning them’. This will not affect mite numbers at all, but it will shoot massive amounts of mite allergen out of the mattress and into the nose and lungs.
Ridding your house of allergens and irritants is, in itself, a hazardous procedure because more of the offending substances will be released into the air during the work. If you take up carpets or remove mattresses, dust-mite allergens and mould spores will be churned up in their millions. Just bundling up a duvet will produce invisible clouds of dust mite allergen - and cat allergen, if your pet once slept on the bed.
Ideally, the allergic individual should not do the work, nor be in the house until it is 100% complete and the house has been very thoroughly aired. This is particularly important for those with chronic sinusitis and mould growth in the house, because of the risk of fungal infections in the sinuses (see p. 32).
If you are an allergy sufferer and have absolutely no choice but to do the work yourself, or to be present, then you should get a good quality dust mask and wear it throughout - only take it off when you go outdoors. Those with atopic eczema and sensitivity to airborne allergens should cover their skin carefully -with clothing, not barrier cream.
An ordinary hardware-shop dust mask is not adequate for most allergens - it only takes out really big particles and lets through all the common airborne allergens except pollen. You need a more serious sort of mask, designed for workplace use and conforming to official standards. Before buying one, ask what is the smallest size of particle that it filters out (at 90% efficiency, or better). Compare this with the particle size of your allergen (given in the articles that follow).
You must be able to breathe well through the mask when physically active, and it must fit tightly against your face, forming a seal at all edges. Beards and moustaches tend to prevent this - as does stubble.
Masks that combine an activated carbon filter with a dust filter will take out gases and chemical vapours as well as particles. Cycle shops now sell such masks -or try an industrial supplier. Such a mask can be useful if you are affected by traffic exhaust or industrial pollution as well as an allergen, for example, or if you are exposed temporarily to wet paint or other fumes at home. Activated carbon masks should also filter out the irritant substances from oil-seed rape plants.
Some people who try the anti-allergen programmes feel much better quite fast. But generally these are long-term strategies - you may not reap any benefits for a few weeks, and the improvement may be small at first. Sometimes it takes several months for the full effects to be felt, so be persistent.

Various other things can irritate the skin and make atopic eczema flare up:
• cold weather
• dry air
• long car journeys
• sweating heavily; clothes or shoes that trap sweat may also cause problems
• dust mites, which can act as an irritant, even if not an allergen
• tobacco smoke
• solvents and other chemicals encountered at work
• skin contact with fruit (especially citrus), vegetables, and sometimes other foods. The spray generated by peeling potatoes can even produce eczema on the face.
Anything which increases blood flow through the skin makes the itching worse:
• heat, especially a hot bath or being too hot in bed
• anger or embarassment
• hot drinks of any kind
• coffee, tea and alcohol because of the drug-like substances they contain
• vinegar and spicy foods
• chocolate, soy sauce, yeast extract, orange juice, tomatoes and other foods that are rich in amines (see p. 200).
Various changes in the body can make the eczema worse:
• teething, in babies
• colds and other viral infections
• in women, certain phases of the menstrual cycle.
Many eczema sufferers are aware that their skin gets worse when they are upset, stressed or anxious Oust before examinations, for example). Like other allergic diseases, atopic eczema is not primarily psychological but, once it has begun, psychological factors can play quite a big part.
The good news…
…for children and teenagers, is that if you have eczema as a child, your chances of developing acne during your teens are greatly reduced.
Contact dermatitis too?
People with atopic eczema can develop contact dermatitis (see p. 54) in addition to their existing rash. There is always this risk with regularly applying creams to your skin, especially anything containing fragrance or lanolin. Antihistamine and antibiotic creams also carry this risk.
Even the ingredients in the creams prescribed for eczema – such as moisturisers and steroids – can sometimes provoke contact dermatitis. Creams are more likely to contain sensitising ingredients than ointments. Very occasionally, the sensitivity is to a preservative or emulsifier that is widely used in different ointments and creams, which means that switching brands yields no improvement. Steroid suspended in petrolatum (white paraffin jelly) is the least likely to cause reactions.
The rash produced by contact dermatitis looks no different from atopic eczema, so this sensitivity will be far from obvious. It will just seem as though the atopic eczema is not getting better.
Talk to your doctor if you think there may be a problem of this kind. He or she can check by using the suspect cream on one side of the body, and a different-but-equivalent product on the other side. Patch tests (see p. 92) may also help to identify contact sensitivity.
Diagnosis
There are five separate aspects to diagnosis:
1 Is this really atopic eczema? There are no clear-cut tests for atopic eczema. Instead the diagnosis is based on a ‘points system’ – how many of the typical features of atopic eczema are present? The doctor adds them up, and if there are enough, then it’s atopic eczema. Sometimes all the typical features are there and this is obviously the right diagnosis, but in other cases there may be room for doubt. The doctor should rule out the possibility of contact
dermatitis (see p. 54), especially if you have eczema only, or mainly, on the hands.
2 What avoidable irritants are making the skin worse?
3 Is the eczematous skin infected? The signs of infection are usually clear, but not always, especially with fungal infections. Steroid creams can sometimes mask the overt signs of infections: if atopic eczema is not responding to treatment this possibility should be investigated.
4 Are there any allergic reactions to those infections? Or to the normally harmless microbes that live naturally on the skin (see p. 17)? Skin-prick tests or blood tests can reveal such allergic reactions where fungi are concerned. Adults with persistent atopic, eczema which is getting worse rather than better are the most likely candidates.
5 Are there allergic reactions (or other sensitivity reactions) to food, or to allergens such as house-dust mite?
This fifth aspect of diagnosis is where controversy is rife. Many dermatologists feel that atopic eczema is treated quite adequately with moisturisers (emollients) and steroid creams. The search for allergic/sensitivity reactions – in other words, for basic causes – seems unnecessary for most patients, or more trouble than it is worth. Indeed, some dermatologists believe that looking for such sensitivity reactions is actually mistaken because they are not basic causes (see p. 42).
Other specialists disagree, and feel that allergic/sensitivity reactions are a basic causative factor in atopic eczema. They concede that there are many false positives, but in their opinion, there are enough true positives in the skin-prick test results to make it worth sorting them out from the false positives. Except for patients with very mild eczema, such doctors prefer to identify and eliminate the root causes, if possible.
Patch tests are now used by some of these doctors (see p. 69) – yet another contentious issue! The time-honoured use for patch tests is in contact dermatitis, and there is a lot of resistance to using them for atopic eczema. Traditionally, the immune reactions involved in atopic eczema and contact dermatitis are seen as entirely different – the former involving IgE and being a quick reaction (identified by skin-prick tests), the latter involving other players and
Sweaty sock dermatitis
More correctly known as ‘juvenile plantar dermatitis’, this rash on the feet affects an awful lot of atopic children. It is frequently misdiagnosed as athlete’s foot, and treated with anti-fungal drugs. The important clue can be found by looking between the toes: if there’s no rash there, then it is not athlete’s foot.
being much slower (identified by patch tests). New research into atopic eczema shows this view to be overly simple (see pp. 18-19) – and it provides a rational basis for using patch tests.
If, as a patient or a parent, you are keen to search for fundamental causes, remember that this should never displace treatments to quell infection or moisturise the skin and restore its protective structure. When these treatments are neglected the whole problem can get far worse, because of the vicious circles that sustain atopic eczema.
Treatment
Treatment for atopic eczema has five possible angles:
1 calming the inflammation
2 avoidance of scratching and rubbing
3 caring for the skin and restoring its normal structure
4 treating infections
5 avoiding allergens.
One or more of these aspects may be neglected, depending on what kind of specialist you are seeing.
Calming the inflammation
Steroid creams are the mainstay of atopic eczema treatment because they calm the inflammation in the skin. The creams do carry a risk of side effects, but are safe when used correctly (see p. 147). An over-fearful attitude to steroids creams can mean that the eczema never gets under control, and this can mean using more steroids in the long run. When treating an outbreak of atopic eczema with steroid cream, it is vital to continue applying the cream until the ‘hidden healing’ has occurred (see p. 146) – don’t stop as soon as the skin looks better.
Promising alternatives to steroid creams now exist: these are tacrolimus and pimecrolimus ointments (see p. 147). Unfortunately they are much more expensive, and your doctor will probably prescribe them only if there is some pressing reason.
Tar-based ointments have a much milder anti-inflammatory effect, and can be helpful for areas of thickened skin. They were once widely used for atopic eczema, but are used less now, in part because they stain fabrics and smell unpleasant. Sometimes they irritate the skin, too, and there are concerns about safety: they contain carcinogens, and significant amounts are absorbed into the bloodstream. However no evidence has been found that these cause cancer, despite intensive searching.
Antihistamine tablets are sometimes used and while they
may not help the eczema much, some evidence suggests that
they could reduce the risk of asthma developing later (see p. 249).
Powerful drugs such as cyclosporin are sometimes used in
severe cases of atopic eczema, to damp down the immune
response. They are taken by mouth, and can affect other parts of the body, not just the skin. Very careful monitoring is needed.
Sunlight is often beneficial, because it suppresses the inflammatory processes in the skin. However, not everyone improves with sun exposure – some get worse. Careful experimentation is the only way to find out: build up the length of sun exposure very gradually, starting with less than an hour a day.
Medical treatment with UV (ultraviolet) light can produce the same effect as sunshine and suppress inflammation. This treatment may be prescribed, but you should not try it for yourself with a sun-lamp. In PUVA treatment, a plant-derived substance called psoralen is given by mouth, or applied to the skin, to enhance the response to UV light.
Kicking the scratching habit
Scratching is a substantial part of the problem in long-standing atopic eczema. Experiments with healthy people and mechanical ’scratching machines’ show that perfectly normal skin will erupt into eczema if it is scratched intensively.
There is no steroid cream powerful enough to counteract the effects of scratching. But if scratching stops, then the skin can –with the help of medication – heal up.
Note that ’scratching’, in this case, includes rubbing the itch (directly or through clothes; using a hand, wrist, chin, leg, foot, or any other part of the body), touching or picking at the skin, rubbing against sheets, furniture or another person, or using a towel, flannel or hairbrush to rub the skin. All these activities can be habitual and quite unconscious, if atopic eczema has been present for more than a few months – you just don’t realise you’re doing it most of the time.
For many with atopic eczema, another problem creeps in –scratching without itching. This may be just habit, a response to boredom, stress or anxiety, or even part of the family dynamics, in which scratching has become a form of emotional expression. Scratching alone can set off itching, and a scratch-itch-scratch cycle ensues.
The first step in combating scratching (for an adult or older child) is simply to notice how often scratching occurs. Doctors at the Chelsea and Westminster Hospital in London issue their patients with little hand-held counting devices (tally-counters), and ask them to press the button on the device every time they scratch or rub. Over a period of days, patients discover – usually to their own amazement – just how often they do scratch. The point of the exercise is simply to become conscious of the scratching impulse, and to notice the situations which typically provoke scratching. You could use a small pocket-sized notebook and pencil to achieve the same end.
Once this awareness has been gained, then you are in a position to break the scratching habit. The methods involved –called ‘habit reversal’ – were first developed by a Swedish dermatologist, Peter Noren. It takes about 2-4 weeks for most people, but the change is long-lasting. Most eczema sufferers find that they recoup their time investment rapidly, once they are free from the chore of dealing with chronic eczema.
When you notice that you are about to start scratching, and before the urge to scratch overwhelms you, take control and do something deliberate with your hands – for example, clench your fists, while breathing deeply and slowly. Think cool non-itchy thoughts. The urge to scratch may pass. If it doesn’t, then you can allay the itch by pinching the itchy area gently, or pressing your fingernail into it, or lightly applying a little moisturiser.
In the bath or shower, don’t use flannels, and never rub or scrub the skin. Dry off by gently patting with a soft towel.
The aim is to get scratching episodes down to fewer than ten per day. In achieving this goal, relaxation exercises, stress management techniques, hypnotherapy or autogenic training (see p. 222) can also be very helpful, especially if you sometimes scratch in tense situations.
With small children, the parents have to do the noticing. Most are unaware just how much their child scratches or rubs the eczema – babies often rub against the side of the cot.
Once the awareness is there, a child over four can usually be taught the habit-reversal technique described above. With a younger child, the parents must distract the child when scratching is imminent, by talking or playing. If the child is scratching while asleep, parents should pick the child up and, very gently, hold the child’s hands away from the body. Situations and activities which commonly provoke scratching should be avoided, or planned for. Give the child something to hold while dressing and undressing, for example – keep the hands busy. But never say ‘Don’t scratch’ – it usually has the opposite effect in the long run.
For the first four days and nights, while you are trying to break the scratching habit, the child should never be alone, even for a minute – someone who is able to distract the child from scratching should always be there, and awake. Fortunately, children lose the habit far more quickly than adults.
Keep a child’s fingernails very short, and smooth them with an emery board too, so that if any scratching does occur the effects are minimised. (Soft cotton mittens, to be worn at night, are often recommended, but the cotton itself can be used to rub the skin – observe your child carefully! The same is true of all-over cotton suits.)
For this anti-scratching programme to be effective in healing the skin, there must be a determined effort with drug treatment at
Will it clear up?
Small children with eczema generally grow out of it by the age of two. Those who have eczema after this age tend to show a big improvement at puberty. Sometimes, however, the eczema can disappear at puberty, only to reappear later: so continue to be careful with your skin.
Atopic eczema is frequently the first sign of a tendency to allergies (see p. 22). Given this early warning sign, parents should take steps to avoid allergies developing, or at least reduce their severity (see pp. 244-9). One small piece of good cheer: atopic eczema and life-threatening food allergies are very rarely found together.
People with both asthma and atopic eczema frequently notice that when one improves the other seems to get worse. There is no explanation for this as yet.
Moisturisers - how to use them
Moisturisers (emollients) do two things: they increase the amount of water in the skin, and they lubricate the skin, making it less brittle.
A moisturiser is designed to leave an oily layer on the surface of the skin which stops the skin’s natural moisture from escaping. The most effective preparations, from this point of view, are ointments made from white paraffin, such as Vaseline, which form an uninterrupted waterproof layer: these are sometimes called occlusives. They contain no water, unlike creams. Although a cream forms a less formidable barrier to the escape of moisture from the skin, it does provide some moisture itself, which can soak into the skin.
The most important thing is to have something that you like using, so that you apply it regularly. There are lots of moisturisers available, so ask the doctor for different ones to try.
Applying moisturiser well is crucial:
• Apply moisturiser before your skin gets dry, as a preventive treatment.
• There’s no need to rub in your moisturiser (this can be a form of scratching). Just apply it very lightly.
• A thin layer is all that’s needed. A thick layer keeps in heat which aggravates the skin.
• Always apply within three minutes of a bath or shower.
• In addition, apply every 3-4 hours during the day. Carrying moisturiser around with you is helpful – get a small tube of moisturiser for this purpose.
• Ask the doctor to prescribe moisturiser in large quantities, to make sure you have enough. But beware of infecting big pots with Staphylococcus bacteria and then reinfecting your skin. Pump-action dispensers are safer.
Moisturiser can also be smeared onto bandages which are then wound around the affected areas at night to reduce the itch – or you can use ready-made ‘wet-wraps’ (ask your doctor about these). As long as the bandages/wraps are immovable, they will reduce nocturnal rubbing and scratching.
Avoid lotions, and any non-prescribed creams, as they could be irritating to the skin. Choose bath oils with care – some contain alcohol which is an irritant.
the same time. You should be using a steroid cream of sufficient strength, twice a day, and plenty of moisturising treatment.
By taking this ‘Combined Approach’, as Dr Christopher Bridgett and his colleages at the Chelsea and Westminster Hospital call it, you should be able to clear the eczema completely, even if you have had it for years and have tried innumerable different treatments. Once this has been achieved, you can maintain an eczema-free state by watching carefully for any outbreaks of itching, redness or roughness, and treating them immediately with a short course of steroid cream (see p. 146).
Skin care
Firstly, avoid all the irritants which you think may affect your skin. Give clothes an extra rinse cycle in the washing machine, to remove all detergent. or use a non-detergent system such as Eco-balls or Aquaballs. Wash all new clothes before wearing them, to remove chemicals such as formaldehyde. Wear soft cotton or silk next to the skin.
Where eczema affects the hands, special care is needed (see p. 57).
Water can be both good and bad for eczema. When you soak in a bath, water is absorbed by the skin cells, which helps correct the dryness of the skin. But when you get out of the bath, and the skin dries, the outermost layer shrinks and develops microscopic cracks, making it even less waterproof than it was before. The way around this is to apply a moisturiser immediately after a bath or shower –gently pat the skin until partially dry, and apply the moisturiser immediately to trap the water in the skin.
For anyone with a severe flare of eczema, current recommendations are:
• soak in lukewarm water for 20 minutes, twice a day
• pat dry
• quickly apply steroid cream to the eczematous areas, then moisturiser over the top, and to all other dry-skin areas
• make sure the moisturiser goes on within 3 minutes of emerging from the water.
This works well for some people, but not all. For a few eczema sufferers, the effect of taking natural oils out of the skin (which soaking does, to some extent) may outweigh the benefits of putting water in. Or they could be sensitive to something in the tap water – the chlorine, perhaps, or pollutants. It may not be obvious that this routine treatment is not helping. As Dr Michael Tettenborn, a British paediatrician with long experience of atopic eczema, observes: ‘By the time they’re referred to me, children are usually on the standard regimen of two-soaks-a-day. One of the first things I do, as an experiment, is tell the parents to just bathe them once a week and use a moisturiser and tissues to keep them clean the rest of the time. Some children do a lot better after that.