Topical administration

This guideline concentrates on topical administration for atopic dermatitis/eczema for children and young people. While this guideline refers to the 'child' throughout, all activities are applicable to young people.

Eczema and dermatitis are terms that are now used synonymously for this type of skin inflammation.

Atopic Eczema is a common inflammatory condition of the skin, affecting one in every five children in the UK at some stage (Goodyear and Harper, 2002). Atopic Eczema is an episodic disease with periods of exacerbation and remission (National Institute of Health and Care Excellence (NICE), 2007).The term atopic describes a group of conditions such as asthma, eczema and hayfever which are linked by the increased activity of allergy component of the immune system the cause of which can be both environmental and genetic (British Association of Dermatology, (BAD) 2013).

Eczema causes the skin to become itchy and inflamed which causes the skin to become red and dry and in severe cases may result in weeping, blistered, crusted, scaly and thickened skin (Peate, 2011). The state of skin can have detrimental effects on the child’s sleep which causes tiredness and irritability (Goodyear and Harper, 2002).  

NICE guidelines (2007) suggest eczema should be treated in a stepped approach which is individualised for each patient. Emollients form the basis of eczema treatment and should be applied regularly even when the skin is clear. Topical steroids are used to treat exacerbations. In severe cases when eczema cannot be controlled with topical creams alone ‘wet wraps’ may be the appropriate form of treatment (BAD, 2013).

Wet wrap treatment consists of tubigauze bandages soaked in steroid being applied to the whole body to provide an occlusive dressing preventing itching and improve retention of the steroid treatment on the skin (Goodyear and Harper, 2002). Wet wraps must not be applied over infected skin without antibiotic cover (NICE, 2007).

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. The skin protects us from microbes and the elements, helps to regulate body temperature, and permits the sensations of touch, heat and cold (Cork and Danby, 2009).

Skin preparations can treat a wide range of conditions and when they are used effectively, care must be taken in assessing the type and severity of the condition being treated.

The same care must be taken as when administering topical medicines, as when administering medicines by any other route (Nicol, 2010).

Background

Topical administration may be used:

  • To treat inflammatory conditions of the skin (eg corticosteroids, immunodulators). 
  • To treat fungal, viral or bacterial infections of the skin (e.g. anti-fungals, anti-virals, antibacterials). 
  • To treat dryness of the skin (eg emollients).
  • To prevent sun damage (eg sunblocks). 
  • To produce superficial analgesia (eg local anaesthetic creams). 

(Consult the British National Formulary or Pharmacist for individual drug information).

Note: close contact with a parent/carer/nurse who has herpes simplex virus (cold sore) should be avoided in a child/young person with eczema (Rationale 1).

Assessment

  • Enquire if the child/ young person has any known drug allergies, and ensure these are documented in the health care record (Rationale 2). 
  • Obtain skin swabs from affected areas of the skin. In general three swabs from different sites are sufficient. Send to microbiology lab for culture and sensitivity (Rationale 3).
  • Assess the child/young person  skin condition and severity, using Patient Orientated Eczema Measure (POEM) questionnaire for children/young people (Charman et al, 2004)(Rationale 4 and 5). 
  • Obtain and document the child/young person history of symptoms (Rationale 6).
  • Consider the complexity of care regime and discuss any compliance issues with the child and family. Involve play therapist with the treatment plan beforehand, to facilitate a positive outcome (Rationale 7). 
  • Discuss the preparation of choice with the child/ young person and  family (Rationales 8 and 9):
    • discuss what the treatment involves and duration 
    • discuss reasons for administration and application
    • discuss side effects of treatment 
    • provide written information
    • give a named contact

Administration

Gather the following equipment: (Rationale 10

  • topical cream/ointment 
  • silver foil bowls 
  • plastic spoon
  • apron 
  • gloves (ensure non latex) (Rationale 11)

Wash hands and put on apron and gloves (Rationale 12). 

Check topical cream/ointment with prescription chart adhering to hospital medicine administration policy for identifying correct patient (Rationale 13).

Apply patient named sticker onto cream tube/bottle (Rationale 14). 

If cream/ointment does not come in a tube or pump dispenser, decant sufficient cream for that administration into a silver foil bowl with plastic spoon (Rationale 15). 

Ensure the child’s/young person’s skin is cleansed thoroughly with a disposable washcloth and prescribed soap substitute (Rationale 16). 

If the child/young person is having a bath prior to topical administration, a bath emollient should be used to reduce water loss from skin and preventing dryness.

The bath water must be lukewarm in temperature to reduce discomfort to sensitive skin (Rationale 17). 

The emollient bath preparation should be poured into the bath (see individual preparations for guidelines on quantity).

The patient should bathe for no longer than 10 minutes (Dawkes,1997)(Rationale 18). 

Sodium laureth sulphate free aqueous cream or emulsifying ointment may be applied liberally as a soap substitute (Rationale 19).

Pat skin dry gently, rather than rubbing, as this creates heat and friction (Rationale 19).

Before administering any cream/emollient to the skin, wash hands and apply non-sterile gloves (Rationale 20).

After the bath, the emollient preparation should be applied to the skin immediately. Cream or ointment formulas may be used (Rationale 21). 

With the named patient’s emollient, apply generously to the skin in the direction of hair growth (Rationale 22).

Steroid creams (used to reduce inflammation) should be applied directly to affected areas (National Eczema Society (http://www.eczema.org/)).

If the prescription for steroid cream is unclear regarding the quantity of cream to apply, discuss this with pharmacist, dermatology CNS or dermatology consultant, the quantity to be used varies with the potency of the preparation.

If both an emollient and steroid cream are used, these should not be applied to the same areas of the body at the same time. The  emollient should be applied 30 minutes after application of steroid cream to affected areas (National Eczema Society website)(Rationale 23).

Note: Steroid creams should be prescribed for the appropriate strength to treat the condition over as short a period as possible. The ongoing use of a steroid cream that is not strong enough to be effective must be avoided (refer to individual products for information) (Rationale 24).

Immunomodulators are ointments/creams applied to the skin can be used following consultation with a Dermatologist or paediatrician 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 the individual Immunomodulator determines the quantity cream to apply. If unsure discuss with pharmacist, dermatology CNS or dermatology consultant. Please refer to Tacrolimus fact sheet for information regarding safety issues (available in the shared care guidelines) (Great Ormond Street Hospital Medicines & Pharmacy website).

Sun protection factor 30+ should be used to avoid sunburn (Rationales 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 (see individual medicine fact sheet/contact pharmacy) (Rationale 28).

Continuation of treatment

The consultant should follow drug guidelines to decide duration of treatment and discuss this with patient/family (Rationales 29 and 30).

In discussion with the consultant, decide appropriate follow-up to reassess following treatment and inform family (Rationale 31).

A clearly written discharge plan must be given to the family.

Document the effectiveness of topical treatment used in patient’s records. Note any changes in the healing process (Rationale 32).

If the topical treatment is not having the desired effect, alternative treatment with wet wraps would be considered as the next step in treatment.

Wet wrap treatment

Wet wrap treatment consists of tubigauze bandages soaked in steroid being applied to the whole body to provide an occlusive dressing preventing itching and improve retention of the steroid treatment on the skin (Goodyear and Harper, 2002). Wet wraps must not be applied over infected skin without antibiotic cover (NICE, 2007).

For guidance on the application of wet wraps and the care of the child receiving treatment with wet wraps see Appendix 1 ‘Nursing protocol of care of the child with wet wraps'.

Rationale

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 using a validated tool, POEM (Charman et al, 2004).
Rationale 6: To ensure an accurate record is maintained.
Rationale 7: To ensure child/young person and family can follow and adhere to treatment guidelines for maximum benefit to patient.
Rationale 8: To educate and inform child/young person and family.
Rationale 9: To ensure maximum benefit to child/young person.
Rationale 10: To be fully prepared to administer treatment.
Rationale 11: To avoid irritation to the child’s/young persons skin.
Rationale 12: To minimise risk of cross-infection, in line with infection control.
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 prevent further irritation to the skin, and remove dirt and debris from the skin reducing risk of providing a medium for bacterial growth (Harper, 2003).
Rationale 20: To minimise risk of infection, and as a protectant against direct contact with skin and cream/ointment.
Rationale 21: To ensure skin does not dry 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/young person 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.

References

Reference 1
British Association of Dermatology (2013) Atopic eczema: Patient information leaflet. 1-9

Reference 2
Charman C, Venn A, Williams HC (2004) The Patient Orientated Eczema Measure: Development and Initial Validation of a New Tool for Measuring Atopic Eczema Severity form the Patients’ Perspective. Arch Dermatol 140: 1513-1519

Reference 3
Cork M J. and Danby S. (2009) Skin barrier breakdown: a renaissance in emollient therapy. British Journal of Nursing 18(14): 872-877 

Reference 4
Dawkes K (1997) How to apply emollients effectively. British Journal of Dermatology 1(2): 8-9

Reference 5
Goodyear H and Harper J (2002) Wet wrap dressings for eczema. An effective treatment, but not to be misused. British Association of Dermatology Vol 146(1): 158-159

Reference 6
Goodyear H (2000) Eczema Herpeticum (3.10) Harper J, Oranji AP, Prose N In: Textbook of Dermatology (Vol 1). Oxford, Blackwell Science

Reference 7
Harper J (2003) Putting eczema into remission - a more positive approach to treatment. Exchange 111: 34-35

Reference 8
National Institute for Health and Care Excellence (NICE) (2007) Atopic eczema in children (CG57). London, National Institute for Health and Care Excellence

Reference 9
Nicol N (2010) Considerations in Topical treatments for Atopic Dermatitis. Dermatology Nursing 22(3): 2-11

Reference 10
Peate I (2011) Eczema: Causes, symptoms and treatments in the community. British Journal of community nursing 16(7): 324-331

Reference 11
Smith C (2004) Topical Immunomodulators – a new treatment for atopic eczema. Exchange 112: 22-23

Appendices

Appendix 1:Wet wrap protocol (542.85 KB)

Document control information

Lead Author(s)

Ann Goulbourne, Clinical Nurse Specialist, Dermatology

Document owner(s)

Ann Goulbourne, Clinical Nurse Specialist, Dermatology

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
19 May 2005
Date approved: 
12 May 2015
Review schedule: 
Three years
Next review: 
12 May 2018
Document version: 
2.0
Previous version: 
1.0