BNF for Children 2011-2012

566 13.5.2 Preparations for psoriasis BNFC 2011–201213 Skinately potent or potent topical corticosteroid which canbe combined with an antimicrobial such as clioquinol.Eczema involving moderate to severe, widespread, orrecurrent infection requires the use of a systemic antibacterial(section 5.1, table 1) that is active against theinfecting organism. Preparations that combine an antisepticwith an emollient application (section 13.2.1) andwith a bath emollient (section 13.2.1.1) can also be used;antiseptic shampoos (section 13.9) can be used on thescalp.Intertriginous eczema commonly involves candida andbacteria; it is best treated with a mild or moderatelypotent topical corticosteroid combined with a suitableantimicrobial drug. For the treatment of nappy rash, seesection 13.2.2.Widespread herpes simplex infection may complicateatopic eczema (eczema herpeticum) and treatmentunder specialist supervision with a systemic antiviraldrug (section 5.3.2.1) is indicated. Secondary bacterialinfection often exacerbates eczema herpeticum.The management of seborrhoeic dermatitis is describedbelow.Management of other features of eczema Lichenification,which results from repeated scratching, istreated initially with a potent corticosteroid. Bandagescontaining ichthammol (to reduce pruritus) and othersubstances such as zinc oxide can be applied over thecorticosteroid or emollient. Coal tar (section 13.5.2) andichthammol can be useful in some cases of chroniceczema. Discoid eczema, with thickened plaques inchronic atopic eczema, is usually treated with a topicalantiseptic preparation, a potent topical corticosteroid,and paste bandages containing zinc oxide and ichthammol.A non-sedating antihistamine (section 3.4.1) may be ofsome value in relieving severe itching or urticaria associatedwith eczema. A sedating antihistamine (section3.4.1) can be used at night if itching causes sleepdisturbance, but a large dose may be needed anddrowsiness may persist on the following day.Exudative (‘weeping’) eczema requires a potent corticosteroidinitially; infection may also be present andrequire specific treatment (see above). Potassium permanganatesolution (1 in 10 000) can be used as a soakin exudating eczema for its antiseptic and astringenteffects; treatment should be stopped when exudationstops.Severe refractory eczema is best managed under specialistsupervision; it may require phototherapy or drugsthat act on the immune system (section 13.5.3).Seborrhoeic dermatitis Seborrhoeic dermatitis(seborrhoeic eczema) is associated with species of theyeast Malassezia. Infantile seborrhoeic dermatitisaffects particularly the body folds, nappy area andscalp; it is treated with emollients and mild topicalcorticosteroids with suitable antimicrobials. Infantileseborrhoeic dermatitis affecting the scalp (cradle cap)is treated by hydrating the scalp using natural oils andthe use of mild shampoo (section 13.9).In older children, seborrhoeic dermatitis affects thescalp, paranasal areas, and eyebrows. Shampoos activeagainst the yeast (including those containing ketoconazoleand coal tar, section 13.9) and combinations ofmild topical corticosteroids with suitable antimicrobials(section 13.4) are used to treat older children.ICHTHAMMOLSide-effects skin irritationLicensed use no information availableIndication and doseChronic lichenified eczemaChild 1–18 years apply 1–3 times dailyIchthammol Ointment, BP 1980Ointment, ichthammol 10%, yellow soft paraffin 45%,wool fat 45%Zinc and Ichthammol Cream, BPCream, ichthammol 5%, cetostearyl alcohol 3%, woolfat 10%, in zinc creamMedicated bandagesZinc paste bandages are used with coal tar or ichthammolin chronic lichenified skin conditions such aschronic eczema (ichthammol often being preferredsince its action is considered to be milder). They arealso used with calamine in milder eczematous skinconditions.For information on available medicated bandages andstockings, see the BNF appendix on wound managementproducts and elasticated garments.13.5.2 Preparations for psoriasisPsoriasis is characterised by epidermal thickening andscaling. It commonly affects extensor surfaces and thescalp. For mild psoriasis, reassurance and treatmentwith an emollient may be all that is necessary. Guttatepsoriasis is a distinctive form of psoriasis that characteristicallyoccurs in children and young adults, oftenfollowing a streptococcal throat infection or tonsillitis.Occasionally psoriasis is provoked or exacerbated bydrugs such as lithium, chloroquine and hydroxychloroquine,beta-blockers, non-steroidal anti-inflammatorydrugs, and ACE inhibitors. Psoriasis may not occuruntil the drug has been taken for weeks or months.Emollients (section 13.2.1), in addition to their effectson dryness, scaling and cracking, may have an antiproliferativeeffect in psoriasis. They are particularlyuseful in inflammatory psoriasis and in chronic stableplaque psoriasis.For chronic stable plaque psoriasis on extensor surfacesof trunk and limbs preparations containing coal tar aremoderately effective, but the smell is unacceptable tosome children. Vitamin D and its analogues are effectiveand cosmetically acceptable alternatives to preparationscontaining coal tar or dithranol. Dithranol isthe most effective topical antipsoriatic agent but itirritates and stains the skin and it should be used onlyunder specialist supervision. Adverse effects of dithranolare minimised by using a ‘short-contact technique’(see below) and by starting with low concentrationpreparations. Tazarotene, a topical retinoid for thetreatment of mild to moderate plaque psoriasis, is notrecommended for use in children under 18 years. Thesemedications can irritate the skin particularly in theflexures and they are not suitable for the more inflammatoryforms of psoriasis; their use should be suspendedduring an inflammatory phase of psoriasis. The efficacyand the irritancy of each substance varies betweenpatients. If a substance irritates significantly, it should