The skin is the largest organ of the body and its paramount function is protection, providing a mechanical, immunological and chemical barrier against the environment (Adams 2001).
Skin preparations can treat a wide range of conditions and when they are used, care must be taken in assessing the type and severity of the condition being treated. The same care must be taken as when administering by any other route (Blawat & Banks 1997).
Note: close contact with a parent/carer/nurse who has herpes simplex virus (cold sore) should be avoided in a child with eczema (Rationale 1).
Background
Topical administration may be used:
- to treat inflammatory conditions of the skin (eg corticosteroids, immunodilators)
- to treat fungal, viral or bacterial infections of the skin (eg anti-fungals, anti-virals, antibacterials)
- to treat dryness of the skin (eg emollients)
- to prevent sun damage (eg sun-blocks)
- to produce superficial analgesia (eg local anaesthetic creams)
(Consult ‘British National Formulary’ guide or Pharmacist for individual drug information).
Assessment
- Obtain and document the child’s history of symptoms (Rationale 2).
- Enquire if child has any allergies (Rationale 3).
- Assess patients skin condition and severity, eg size of affected area (Rationale 4 and 5).
- Consider whether a swab is required (Rationale 6).
- Consider complexity of care regime and compliance issues (Rationale 7).
- Discuss preparation of choice to child and family (Rationale 8 and 9):
- provide written information if available
- discuss reason for administration
- discuss side effects of treatment
- discuss what the treatment entails and likely duration
Administration
Gather the following equipment: (Rationale 10)
- topical cream/ointment
- silver foil bowls
- plastic spoon
- apron
- gloves (non-latex if patient has latex allergy)(Rationale 11)
- Wash hands and put on apron (Rationale 12).
- Check topical cream/ointment with prescription chart following hospital policy for identifying correct patient (Rationale 13).
- Put patient name sticker on cream tube/bottle (Rationale 14).
- If not a tube with pump dispenser, decant some cream into a silver foil bowl with plastic spoon (Rationale 15).
- Ensure skin is cleaned thoroughly and allow it to dry (Rationale 16).
- If having a bath prior to topical administration, emollients (reduce water loss from skin preventing dryness) maybe used.
- The bath water must be lukewarm in temperature (Rationale 17).
- The emulsifying bath preparation should be poured into the bath (see individual preparations for guidelines on quantity).
- The patient should bathe for no longer than 10-15 minutes (Dawkes 1997)(Rationale 18).
- Aqueous cream or emulsifying ointment may be applied liberally as a soap substitute (Rationale 19 and 20).
- Pat skin dry gently (Rationale 19 and 20).
- Put on non-sterile gloves (Rationale 19 and 20).
- After the bath the emollient preparation should be applied to the skin immediately. Cream or ointment formulas may be used (Rationale 21).
- Generously dot the skin with the named patient’s emollient and smear gently and quickly in a downward motion (Rationale 22).
- Steroid creams (used to reduce inflammation) should be applied directly to affected areas (National Eczema Society website).
- (Note: depending on potency of cream determines how much cream to apply. If unsure discuss with pharmacist, dermatology CNS or dermatology physician).
If an emollient is also used, this should not be applied to the same areas as the steroid cream. Otherwise apply emollient 15-30 minutes after application of steroid cream to affected areas (National Eczema Society website)(
Rationale 23).
Note: The on-going use of steroid cream that is too weak and ineffective must be avoided (refer to individual products for information)(
Rationale 24).
Immunomodulators are ointments/creams applied to the skin and to be used following consultation with a Dermatologist or Physician who is experienced in the treatment of atopic dermatitis:
They are licensed for use on patients aged two years and over with atopic dermatitis.
The potency of cream determines how much cream to apply. If unsure discuss with pharmacist, dermatology CNS or dermatology physician. (Please refer to Tacrolimus fact sheet for information regarding safety issues in the shared care guidelines)(Great Ormond Street Hospital Medicines & Pharmacy website).
Sunblock should be used to avoid sunburn (
Rationale 25 and 26)(
Smith 2004)
All creams should be single named patient use only and disposed of after discontinuation of treatment (
Rationale 27).
Advise patient and family to observe for any adverse effects during treatment (
Rationale 28).
Continuation of treatment
The Physician should follow drug guidelines to decide duration of treatment and discuss this with patient/family (
Rationale 29 and 30).
In consultation with physician, decide appropriate follow-up to reassess following treatment and inform family (
Rationale 31).
Document the effectiveness of topical treatment used in patient’s records. Note any changes in the healing process (
Rationale 32).
Rationale 1: There is a serious risk of developing eczema herpeticum (
Goodyear 2000).
Rationale 2: To ensure that the topical preparation chosen by physician for treatment can be used safely.
Rationale 3: To ensure any infection is correctly diagnosed.
Rationale 4: To diagnose skin condition and consider which topical treatment to use.
Rationale 5: To provide a baseline of assessment.
Rationale 6: To ensure an accurate record is maintained.
Rationale 7: To ensure child /family can follow and adhere to treatment guidelines for maximum benefit to patient.
Rationale 8: To educate and inform child and family.
Rationale 9: To ensure maximum benefit to child.
Rationale 10: To be fully prepared to administer treatment.
Rationale 11: To avoid irritation to the child’s skin.
Rationale 12: To minimise risk of cross-infection.
Rationale 13: To ensure correct topical treatment is given to correct patient.
Rationale 14: For single patient use only to minimise risk of cross-infection.
Rationale 15: To minimise risk of cross-infection.
Rationale 16: Skin is then clean to begin application of treatment.
Rationale 17: A higher temperature will lead to dilation of blood vessels and increased itching.
Rationale 18: To prevent skin drying out.
Rationale 19: To remove dirt and debris from the skin reducing risk of providing a medium for bacterial growth (
Harper 2003)
Rationale 20: To minimise risk on infection and as a protectant against direct contact with skin and cream/ointment.
Rationale 21: To ensure skin has not dried out.
Rationale 22: This follows the natural hair fall and increases absorption.
Rationale 23: To ensure steroid cream is absorbed effectively.
Rationale 24: It is better to use a stronger cream to clear the eczema rapidly.
Rationale 25: Long-term use of immunomodulators may increase the risk of skin cancer.
Rationale 26: Immunomodulators can inhibit some of the actions of the immune system in the skin, which usually maintains skin cells in a healthy state.
Rationale 27: To avoid the risk of cross-infection.
Rationale 28: To ensure safety in administration and treatment.
Rationale 29: To ensure appropriate duration time for effectiveness.
Rationale 30: To keep the child and family informed.
Rationale 31: To reassess skin, observing effectiveness of treatment.
Rationale 32: To provide an evaluation of the treatment and to maintain an accurate record.
Reference 1:
Adam S (2001)
Understanding basic skin function, dry skin and emollients. Professional Care of Mother & Child 11 (2): 46-7.
Reference 2:
Blawat D, Banks P (1997)
Comforting touch. Using topical skin preparations. Nursing 27 (5): 46-8.
Reference 3:
Dawkes K (1997)
How to apply emollients effectively. British Journal of Dermatology 1 (2): 8-9.
Reference 4:
Smith C (2004)
Topical Immunomodulators – a new treatment for atopic eczema. Exchange 112: 22-23.
Reference 5:
Goodyear H (2000)
Eczema Herpeticum (3.10) Harper J, Oranji AP, Prose N In: Textbook of Dermatology (Vol 1). Oxford, Blackwell Science
Reference 6:
Harper J (2003)
Putting eczema into remission - a more positive approach to treatment. Exchange 111: 34-35.
Reference 7:
Courtney M (2002)
NTplus - Nurse prescribing and dermatology. Nursing Times 98(30): 53-54.
Document control information
Lead author(s)
Ann Goulbourne, Clinical Nurse Specialist, Dermatology
Document owner
Ann Goulbourne, Clinical Nurse Specialist, Dermatology
Approved byClinical Practice Committee
First introduced: 19 May 2005
Date approved: 21 December 2011
Review schedule: Two years
Next review: 23 December 2013
Document version: 1.0
Replaces version: N/A
