Dermatology Treatment Guidelines

Page 1 of 33
DERMATOLOGY TREATMENT
GUIDELINES
Folder Ref No: 46

Signed: ... Date : .
Clinical Governance Lead GP

Signed: ...... Date : .
Executive Director

Date of Issue: June 2008
Version No: 1.4
Date of Review: June 2010
Author: Val Anderson, Dermatologist Nurse
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If you need further copies of this document please contact Vicky
Bawn, Quality and Performance Support Manager, 0117 330 2454
Organisation Name
Document status: (draft or current as applicable)
Version Date Comments
1.0 03/03/08 Valerie Anderson submitted references etc
1.2 03/04/08 Format of guidelines amended
1.3 16

/04/08 Sent to Val for approval of format
1.4 28
th
April 2008 Sent to P&G ratification Group. Approved
1.4 22
nd
May 2008 Approved by Integrated Governance
Committee

Page 3 of 33
CONTENTS PAGE

1.0 Introduction 4
2.0 Treatment and Management of Psoriasis (Adult) 5
2.1 Appendix A
Rationale for the Treatment of Psoriasis 6
3.0 Treatment and Management of Eczematous and
Psoriatic Scalp Problems (Adult) 9
3.1 Appendix C
Rationale for Treatment and Management of
Eczematous and Psoriatic Scalp Problems 10
4.0 Treatment and Management of Atopic Eczema (Adult) 13
4.0 Treatment and Management of Atopic Eczema (Child) 14
4.1 Appendix E
Rationale for the Treatment and Management of Atopic Eczema 15
5.0 Treatment and Management of Scabies (Adult) 19
5.1 Table 3 - Guidelines for the Effective Treatment of Scabies 20
5.2 Table 4 - Extra Precautions to be taken in cases of
Crusted Scabies 21
5.3 Table 5 - Action Plan To Effectively Manage One or
More Cases of Scabies in a Nursing/Residential Home 21
5.4 Appendix G
Rationale for Treatment and Management of Scabies 22
6.0 Treatment and Management of Hand and Foot Eczema (Adult) 24
6.1 Appendix I
Rationale for the Treatment and Management of Hand and
Foot Eczema 25
7.0 Table 1 - Emollients 30
71. Table 2 Topical Steroids Potencies 31
8.0 Application of Emollients (moisturisers) Advice Sheet 32
9.0 Audit Tool 33
10.0 Equality impact assessment 33
10.0 References 33
11.0 Bibliography 33
12.0 National Patient Safety Agency fire hazard leaflet

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DERMATOLOGY TREATMENT GUIDELINES

1. Introduction

Purpose

To act as a guidelines for health professionals, who are not dermatology specialists,
in the care of chronic inflammatory dermatitis in primary care.

Principles

This guideline is intended to be used within the competency levels of those referring
to it. If the health professional does not feel fully competent advice is to be sought
from the dermatology nurse specialist.

Page 5 of 33
2.0

Treatment and management of
Psoriasis (Adult)

Holistic assessment and history taken.
Skin assessed, extent of disease and
present treatments recorded.

Treatment regimen planned with patient
following agreed protocols

General regimen plus
that for each affected
area.

Affected
area

First line treatment
Review at 4-8 weeks

Second line treatment to
start if poor response noted
by week 4-8.

Face, ears
and hairline

- Mild topical steroid
eg, 1% hydrocortisone
oint. Or Alphosyl HC
cream.
- Ears- As above plus
topical steroid drops to
canal.

Use moderate potency topical
steroid eg. Eumovate oint.
plus short contact
dithranol/dithrocream to
thickened areas particularily
around hairline.

Chronic
Plaque

- Vit.D analogue or
- Dithrocream
short/moderate
contact plus moderate
potency topical
steroid e.g. Betnovate
RD oint. +/- 5% tar or
Stiedex LP cream.

Thicker plaques may need
dithranol in lassars paste plus
potent topical steroid eg.
diprosalic oint. +/- duoderm
occlusion or Dovobet
Ointment OD ( max 4 week
use then revert to first line
treatment).

Guttate
Psoriasis

Mild topical steroid +/-
tar eg Alphosyl HC
cream
+/- vit D analogue
Consider conjunct ref
for TL01 UVB

Try moderate potency steroid
eg Eumovate oint. +/- vit D
analogue or dithrocream to
thicker plaques.

Flexural
Psoriasis
and Genital
area

Mild/moderate topical
steroid eg 1%
hydrocortisone oint or .
Trimovate cream

Consider a higher potency
steroid for 3-4 days such as
Locoid C.

Following
assessment a
planned teaching
programme will be
implemented, which
aims to provide
support and enable
the patient to
understand his/her
condition and
recognize the most
effective treatments.
This will include
advice on use of
emollients, when
washing and avoiding
astringent substances
that may dry skin.
Encouraging to
moisturise skin
regularly as part of
their skin care
regimen.
- Use a soap
substitute, such
as Aqueous
Cream or
Emulsifying
Ointment.
- Use an emollient
bath additive,
such as Polytar ,
Oilatum,E45 or
Balneum Plus
- Moisturise skin
at least daily with
a tolerated
emollient. (See
table 1 for
emollient advice)

Plantar and
palmar
Psoriasis

Potent topical steroid
eg diprosalic oint,
elocon oint or
dermovate oint.

Try polythene occlusion of
topical agents, for one week
max..Soften hyperkeratotic
areas with keratolytic agents
Moderate clearance should be noted by weeks 6-8. If yes continue and modify for discharge around
week 12. If not then referral to Secondary care may be required; this also remains an option if the patient
has a flare at any time.
Refer to Appendix A for the rationale behind treatment protocols, methods of patient review and
discharge planning. Refer to Appendix B for teaching plan.

Page 6 of 33
2.1 Appendix A
Rationale for the treatment of Psoriasis

Action Rationale
Carrying out a holistic assessment. Skin conditions can often be related to
other health problems and certain
medication. Also there can be a great
psychological and social impact of the
disease. Environmental factors and
triggers like stress, trauma and alcohol
intake can exacerbate psoriasis.
Extent of psoriasis and present treatments
recorded.
A clear assessment of skin is vital so that
correct treatment can be identified and that
improvement or flares can be recorded
comparatively. Previous experience of
treatments is useful firstly to determine
their effectiveness, secondly to gain insight
into the patients perspective and factors
which may influence their willingness to
continue with further treatment.
A regimen is planned with the patient
following agreed protocols.
It is vital to work with the patient and
negotiate achievable goals for treatment,
the patients physical ability, and
understanding, external commitments and
motivation need to be taken into account.
Agreed treatment protocols are vital in
nursing practice, thus ensuring uniformity
and good standards of care; additionally as
a formal record they act as a reference
guide when considering accountability.
The regimen will include some core goals
and will incorporate a formal teaching plan.
The belief is held that patients will follow a
particular route through treatment and
achieve common or core objectives;
acknowledging that patients have
individual needs, these pathways will be
altered accordingly. It is vital that a
treatment regimen facilitates patient
education to enable understanding of their
condition and the most effective treatment.
Approaching core goals in this way
encourages uniformity and maintenance of
care standards in a formal way.
Advise to use of soap substitutes and
emollients.
Soaps and shampoos are astringent and
can dry the skin. The aim is to improve the
general skin condition by moisturising and
removing scale. This emollient preparation
primes the skin for other topical agents and
reduces cracking making the skin more
comfortable.

Page 7 of 33
Appendix A

Action Rationale
Patient education is aimed at enabling the
patient to understand his/her skin condition
and recognize the most effective
treatments.
Patients need a clear understanding of
their skin condition in order to comprehend
the benefits of certain treatments. Tores
and Tilford link patient education with
patient satisfaction, which in turn prompts
a change in behaviour. This of course is
very relevant to the extent to which the
patient will comply with the treatment
protocol suggested to them. In addition, if
patients are to recognize the benefits of
their potential treatments, they must
understand their actions and possible side
effects. E.g. correct application of topical
steroids can minimize potential side effects
and careful application of dithranol
preparations can avoid staining and
burning to unaffected areas.
Using topical steroids in the treatment of
psoriasis.
Mild to moderate potency topical steroids
are useful in the treatment of psoriasis.
They reduce inflammation and are often
the first choice to areas such as face, ears,
hairline and flexures.

In flexural areas they
are commonly combined with antifungals.
Plus other combinations e.g. with salicylic
acid can reduce scaling and flatten
hyperkeratotic areas.
Potent topical steroids are only used to
specific areas and their progress and
usage are monitored carefully.
Sometimes there can be a rebound
phenomenon occur when potent topical
steroids are stopped. Additionally, it is
beneficial to reduce to a moderate to mild
potency steroid to limit the long - term side
effects, however with correct usage to
specific areas e.g. hyperkeratotic plaques,
these side effects can be kept to a
minimum.
Using tar based products in the treatment
of psoriasis.
Coal tar has anti-inflammatory and
antiscaling properties it also has an
antimitotic effect however its exact action
is unclear.

Tar products may cause patient
compliance problems, as they are messy
and odorous. However modern tar
products are a little better tolerated.
Using vitamin D analogue creams. These are thought to act by enhancing the
differentiation of epithelial cells, a stage of
epidermal development missing in psoriatic
skin.

These treatments are well tolerated
due to ease of application, plus negligible
mess and smell.
Page 8 of 33
Appendix A

Action Rationale
Using dithranol preparations in the
treatment of psoriasis.
Dithranol has an antimitotic action, there
for slowing down the rapid cell division.
Dithranol is available as cream, ointment
or paste. The vehicle of choice depends on
the site affected, thickness of plaques as
well as patient preferences and time
available. It is commonly used for short
contact treatment, where by the patient will
apply it to specific psoriatic plaques,
leaving it in situ for up to one hour then
carefully washing it off. The benefits of this
method are that staining and irritation can
be minimalised.
Using occlusion to thicker plaques. Occlusion concentrates the effects of the
moisturiser and topical steroid. It is a
useful way of softening areas of
hyperkeratosis.

Methods of patient review and discharge planning

Action Rationale
Review patients regularly whilst
undergoing treatment.
To assess efficacy of treatment.
Observe for signs of soreness or irritation
due to treatment.
Provide support and encouragement
clearance may take up to 12 weeks, if
morale is poor compliance may also suffer.
To provide a forum for patient education.
Assess and record skins appearance at
each visit.
To observe for scale reduction, smoothing
(and staining if using dithranol).
Observe for erythema or soreness.
For clear record keeping and showing
awareness of personal accountability.
Building rapport, being accessible, flexible
and contactable.
The aim of the treatment plan is to give
patients the confidence to treat themselves
at home and manage their own skin
condition. Being an effective resource can
facilitate this process.
Reducing frequency of visits as skin
improves, guiding patients through
decision making and making use of the
treatments they have available
Encouraging patients to use their
knowledge of their condition and
treatments. To promote independence.
Have clear guidelines of patient routes for
re-referral once discharged.
To reduce misunderstandings, to promote
an efficient service.

Page 9 of 33
3.0

eczematous and psoriatic
scalp problems (Adult)

Scalp assessed, extent of affected
areas and present treatment recorded.

. Treatment regimen
planned with
patient following agreed
protocols.
Incorporating the core
plan of care.

Presentatio
n of scalp
condition
First line treatment.
Review at 1-4
weeks
Second line
treatment, to be
started if poor
response noted
by week 4.

Psoriatic
with
light scale

- Vit D analogue
scalp application eg
Dovonex
orTar/sulphur/salicyli
c acid eg Cocois oint

Try adding a
potent topical
steroid scalp
application eg
diprosalic scalp
application.

Psoriatic
with thick
scale

-
Tar/sulphur/salicylic
acid eg Cocois oint
+/- a steroid scalp
application eg
diprosalic.
- Soften thicker
scale via occlusion
of keratolytic agent
or emollient

Try occluding
Tar/sulphur/salic
ylic acid eg
Cocois oint
nocte or short
contact
dithrocream plus
steroid
application

Eczematous
dry and
scaly.

- Emollient to lift
scale and ease
dryness
- Steroid scalp
application in
aqueous base

Tar/sulphur/salic
ylic acid eg
Cocois oint may
be tolerated to
specific areas.

Core plan of care.
This follows initial
assessment and is a
planned teaching program
the implementation of this
provides support, enabling
the patient to understand
his/her condition and
recognize the
most effective treatments.

The educative program will
cover cleansing of the
scalp. If psoriatic in origin
then a tar based shampoo
can be used, eg. Polytar,
Alphosyl or T gel.
If tar is not tolerated then a
mild baby shampoo is
recommended.
An eczematous scalp may
tolerate a mild baby
shampoo eg Immuderm or
Vantage, if not a light soap
substitute can be used eg
Dermol 500.

Eczematous
inflamed
and weepy.

- Steroid scalp
application in
aqueous base eg
synalar gel or dot
with topical steroid/
anti bacterial to
weepy areas eg
Fucibet.

Take swab for
microculture and
sensitivity.
Consider need
for antibiotics +/-
refer to
consultant
dermatologist.

Moderate clearance should be noted by 6-8 weeks. If yes continue and modify treatment for
discharge around week 10-12. If not then referral to Secondary care may be required; this also
remains an option if the scalp flares at any time.
Refer to Appendix C for the rationale behind treatment protocols, methods of patient review
and discharge planning. Refer to Appendix D for teaching plan.

Page 10 of 33
3.1 Appendix C
Rationale for treatment and management of eczematous and
psoriatic scalp problems

Action Rationale
triggers like stress, trauma and alcohol
intake can exacerbate the skin condition.
Extent of psoriasis and present treatments
recorded.
motivation need to be taken onto account.
Page 11 of 33
Appendix C

Action Rationale
Educating the patient about cleansing
his/her scalp.
Cleansing allows scale, crusted exudates
and residual topical preparations to be
lifted from the scalp. The method of
cleansing will alter depending on the
condition. E.g. an eczematous scalp needs
a mild cleansing agent with gentle
agitation, whereas a scale is actively lifted
from a psoriatic scalp during washing.

This educative process informs the patient
of the correct technique (e.g. to wash hair
separately from the bath or shower as
shampoo suds will drizzle down the
patients back and may aggravate their
skin.), plus acknowledging the therapeutic
benefits of additives, such as tar for its
antimitotic effects.
It introduces the concept of planning a
regular treatment regimen at home.

Using a vitamin D analogue to a lightly
scaling psoriatic scalp.
This is a well-tolerated treatment as it is
odourless and easy to use, which are
important factors when considering
compliance.
Patients should be informed that no more
than 60mls of solution to be used In one
week, or less if also using cream/ointment,
due to the risk of hypercalcaemia.
Using a mix of tar/sulphur/salicylic acid on
a scaly scalp.
Initially messy to use, but with correct
application it can be used without too much
grease in the hair.
The greasy mixture softens scale allowing
it to be lifted with a comb. The tar acts as
an antimitotic, whilst the sulphur and
salicylic acid work to reduce the surface
scale.
Using liquid paraffin to scalp/with occlusion This is a way of moisturizing a dry scalp;
occlusion will concentrate these effects
and help to loosen thicker scale.
Using dithrocream to scalp. Fixed psoriatic scale may benefit from
dithrocream, which has an antimitotic
effect.
The patient must be aware of the irritant
and staining effects and the importance of
avoiding contact with the face and eyes.
Using a topical steroid on the scalp. The scalp can tolerate potent topical
steroid applications. These have an anti-
inflammatory effect and are therefore
useful both in the treatment of eczema and
psoriasis. Combinations with for instance
salicylic acid in Diprosalic can be
beneficial.
Regularly reviewing a weepy scalp. Taking
a swab for micro culture and sensitivity.
Staph. Aureus can act as a flare factor
(8)

The need for oral antibiotics needs to be
assessed.
Page 12 of 33
Appendix C


Action Rationale
Observe for signs of soreness or irritation
due to treatment.
clearance may take up to 12 weeks, if
morale is poor compliance may also suffer.
each visit.
To observe for scale reduction, smoothing
(and staining if using dethrone.), improved
integrity and less excoriations.
Observe for erythema or soreness.
Encourage the patient to involve a relative
or friend in treatment. Invite the individual
to attend a demonstration session of how
treatment should be applied.
The scalp is very difficult to treat
independently; having someone who is
competent and confident to do the
treatment for them will aid their
compliance.
and contactable.
re- referral once discharged.

Page 13 of 33
4.0

atopic eczema. (Adult)

Skin assessed, extent of affected

. Treatment regimen
planned with patient
following agreed
protocols.
Incorporating the
core plan of care.

Presentatio
n of
condition
and areas
affected.

Review at 4-8
weeks
Second line
treatment, to be
started if poor
response noted 4 -
8 weeks

Dry scaling
and inflamed
face, ears
and flexures

Use a mild topical
steroid to these
areas twice daily

Step up to a
moderate potency
steroid for one week
then review.

Dry, scaly
and itchy
trunk and
limbs.
Use moderate
potency topical
steroid twice daily.
Plus see emollient
advice on table 1.
Consider oral
antihistamine.

Step up to potent
steroid to persistent
areas Or try wet
wraps with moderate
/mild potency
steroid. Review 1-2
weekly.

Dry and
inflamed
trunk and
limbs.
Use a potent topical
steroid in a cream
form initially, and
then reduce to a
moderate potency
as inflammation
reduces.
Try wet wraps with
moderate potency
steroid, review 1-2
weekly, and then
reduce to tubular
coverings.

Inflamed,
fissured,
weepy and
crusting to all
areas.

Refer to table 1. for
emollient advice.
Use potent topical
steroid plus anti
bacterial agent. Use
diluted KMNO4 as
compress/soaks to
weepy areas.
Reduce to moderate
potency steroid as
skin improves.

Send a skin swab for
micro culture and
sensitivity, consider
oral antibiotics.
Once potential
infection has settled
try paste bandages
to fissured and
excoriated areas.
Revert to tubular
coverings when raw
areas have healed.

Core plan of care.
assessment and is a
planned teaching
program the
implementation of
this provides support
and guidance,
enabling the patient
to understand
recognize the most
The educative
program will
emphasize the
importance of
avoiding astringent
substances such as
soaps and
shampoos.
Soap substitutes are
recommended, in
addition to an oil
additive to
bath/wash water.
Skin should be
moisturised at least
2/3 times daily or
whenever skin is dry
All topical steroid
applications should
be used in
conjunction with
emollients. See table
1. for further details.
Where possible
tubifast coverings
are recommended to
use with topical
applications.

Lichenified
areas.

Moderate to potent
topical steroid.

Try paste bandages
to affected areas or
a thin hydrocolloid to
smaller areas.

Moderate clearance should be noted by 8 10 weeks. If yes continue and modify treatment for
discharge around week 12-14. If not then referral to Secondary care may be required; this
also remains an option if the skin flares at any time.
Refer to Appendix E for the rationale behind treatment protocols, methods of patient review
and discharge planning.

Page 14 of 33
4.0

atopic eczema. (CHILD)

Skin assessed, extent of affected

. Treatment regimen
following agreed
protocols.
Incorporating the
core plan of care.

Presentatio
n of
condition
and areas
affected.

Review at 4-8
weeks
Second line
treatment, to be
started if poor
response noted 4 -
8 weeks

Dry scaling
and inflamed
face, ears
and flexures

Use a very mild
topical steroid to
these areas twice
daily (hydrocortisone
0.5%)

Step up to a mild
potency steroid for
one week then
review.

Dry, scaly
and itchy
trunk and
limbs.
Apply emollient (see
emollient advice on
table 1). Consider
oral antihistamine.
Use mild topical
steroid to persistent
areas Or try dry
wraps over
emollients. Review
1-2 weekly.

Dry and
inflamed
trunk and
limbs.
Use a mild topical
steroid initially, and
then reduce to
emollients only as
inflammation
reduces.
Try dry wraps with
mild potency steroid,
review 1-2 weekly.

Inflamed,
fissured,
weepy and
crusting to all
areas.

Refer to table 1. for
emollient advice.
Use mild/moderate
topical steroid plus
anti bacterial agent.
Reduce steroid
potency as skin
improves.

Send a skin swab for
micro culture and
sensitivity, consider
oral antibiotics.
Once potential
infection has settled
try paste bandages
to fissured and
excoriated areas.
Revert to tubular
coverings when raw
areas have healed.

Core plan of care.
assessment and is a
planned teaching
program the
implementation of
this provides support
and guidance,
enabling the patient
to understand
recognize the most
The educative
program will
emphasize the
importance of
avoiding astringent
substances such as
soaps and
shampoos.
recommended, in
addition to an oil
additive to
bath/wash water.
Skin should be
moisturised at least
2/3 times daily or
whenever skin is dry
All topical steroid
applications should
be used in
conjunction with
emollients. See table
1. for further details.
Where possible
tubifast coverings
are recommended to
use with topical
applications.

Lichenified
areas.

Mild to moderate
topical steroid.

Try paste bandages
to affected areas or
a thin hydrocolloid to
smaller areas.

Moderate clearance should be noted by 8 10 weeks. If yes continue and modify treatment for
discharge around week 12-14. If not then referral to Secondary care may be required; this
also remains an option if the skin flares at any time.

Page 15 of 33
4.1 Appendix E
Rationale for the treatment and management of atopic eczema

Action Rationale
triggers like stress can aggravate eczema
Extent of eczema and present treatments
recorded.
motivation need to be taken into account.
Page 16 of 33
Appendix E

Action Rationale
emollients.
can dry the skin. Advocating an effective
skin care regimen using emollients is the
essence of eczema management. Bathing
with an emollient is a moisturizing and
cleansing experience.
(9)
The cleansing
action removes dead skin cells and
residual topical medicaments. Bathing with
emollients offer further treatment options
e.g. antibacterial for widespread
excoriation or antipruritic for a very itchy
skin.
Emollients act to reduce loss of skin
moisture and help restore the lipid barrier
imbalance.
(10)
For the emollient to work as
an effective barrier it must be reapplied at
least 2-3 times daily, 4-5 times if possible.
The range of emollients is wide and varied
so the patient needs to be clearly advised
so that they can make an informed choice
of the one which suits them and their skin.
treatments.
the benefits of certain treatments. Tones
steroids can minimize potential side
effects.
All topical steroid applications should be
used in conjunction with emollients. Where
possible tubifast coverings are
recommended.
Using a combination of topical steroids and
emollients works very effectively for the
treatment of eczema. Topical steroids are
more rapidly absorbed when applied to
well moisturised skin. The ideal is to apply
the moisturiser 20 minutes prior to steroid
application
.
Tubifast coverings hold creams
and ointments in place, providing mild
occlusion and can prevent the individual
harming their skin if they scratch.
eczema.
Topical steroids suppress various
systematic components of the
inflammatory reaction. Topical steroids can
be combined with antibacterial and
antifungal agents.
Page 17 of 33
Appendix E

Action Rationale.
Potent topical steroids are only used to
specific areas and their progress and
usage are monitored carefully.
It is important to regularly review a patient
using a potent topical steroid, so that as
skin improves a step down to a moderate
then mild potency steroid can be made to
limit the long - term side effects, however
with correct usage, these side effects can
be kept to a minimum.
Patient education should include the
correct usage of topical steroids.
Generally people are concerned about
using topical steroids. It is important to
allay these fears with some clear facts and
guidelines that can be followed.
Reassuring the patient about these issues
can improve patient compliance and
ensure correct usage. Although overuse
can be a problem so can under use. It is
better that the correct quantities are used
for a shorter length of time, than too little
steroid over a long length of time with
frequent flares.
Recommending oral antihistamines. These can be useful short term to relieve
pruritis and may help to break an itch
scratch cycle, particularly if scratching is
occurring in the sleep. Depending on
choice they can have a sedative effect.
Using wet wraps in eczema management. Often used to control itch scratch cycle.
They are not suitable for weepy or infected
eczema. They involve applying a warm,
moist tubifast covering over skin treated
with emollient and a mild topical steroid.
This creates a cooling effect through
evaporation, rehydration via emollients,
protection from scratching, allowing
excoriations to heal and improved steroid
absorption.
Using potassium permanganate (KMN04)
to weepy areas.
This is an astringent oxidizer, which is
used for its cleansing/antiseptic effects and
for its drying effects on weepy skin. It can
be an irritant and care must be taken to
dilute it and use correctly. (See table 5)
Taking a skin swab for micro culture and
sensitivity.
There are many topical agents available
that have antimicrobial properties. These
may be useful in the management of
localized infection, however if there is
generalized infection then systemic
antibiotics may be necessary. A moist skin
swab should be taken to clarify antibiotic
sensitivity.
It is vital to be aware of the potential of
viral and fungal infections. (See table 6).
Page 18 of 33
Appendix E

Action Rationale
Using paste bandages. These are helpful in the management of
excoriated, inflamed and lichenified
eczema. They are occlusive and offer
similar benefits to the wet wraps. There are
a variety of paste bandages available; the
choice depends on skin presentation and
patient tolerance.
Using occlusion to thicker lichenified areas. Occlusion concentrates the effects of the
hyperkeratosis.

Methods of patient review and discharge planning.

Action Rationale
clearance may take 12 weeks or more, if
morale is poor, compliance may also
suffer.
Assess and record the skins appearance
at each visit.
To monitor the response to treatment and
to make modifications to treatment plan to
meet changing patient needs.
Observe inflammation, weeping or other
signs of infection.
and contactable.
If appropriate involve a relative or
significant other in treatment and
education.
Eczema is a chronic skin disease that may
flare intermittently; if the patient has
support from a relative/partner then it might
strengthen their ability to cope. Also topical
treatments are lengthy and messy help
with these at home is always welcomed.

Page 19 of 33
5.0

scabies (Adult)

Skin assessed, signs of infestation
noted. Treatment to date of patient plus
family members and contacts recorded.

. Treatment regimen
Incorporating the core
plan of care.

Presentation
of condition
(See below
for clinical
signs).

Review at 7-10
days.
Second line
treatment,

Clinical
signs of
infestation
with no
previous
scabicide
treatment.

Treat with Malathion
or Permethrin
following guidelines
on table 3.
Repeat after ten
days.

Check that guidelines
were followed rigidly,
reassure and guide
through a further
application. Use
Permethrin if not
pregnant adult.

Previous
treatment
with
scabicide,
clinical signs
still evident.

Offer a further
application of
scabicide; Preferably
Permethrin if non
pregnant adult.
Review patients
understanding of
guidelines.

A maximum of weekly
application for 3 weeks
should not be
exceeded.
Therefore give the
third application, if
already given guide
through emollient
therapies and review
in 10 days.

Clinical
signs of
crusted
scabies

Instigate treatment as outlined previously. Take
extra precautions as highlighted on table 4.
Lead a coordinated approach in treating the
individual, tracing contacts and preventing
spread of scabies, particularly in the care setting.

Core plan of care.
assessment and is a
planned teaching program
the implementation of this
provides support, enabling
the patient to understand
understand the importance
of treating it correctly.

The educative program will
cover correct application of
treatments, the importance
of tracing close contacts
and ensuring that they also
receive treatment.

Residual
pruritic rash,
post
effective
scabicide
treatment.

Instigate the use of soap substitute and
emollients as outlined in the treatment of eczema
protocol. Sometimes a cream containing
crotamiton (Eurax) can be a useful antipruritic,
which also has an anti-scabetic effect.
(9)

Otherwise a mild to moderate potency topical
steroid will calm the inflammatory reaction. Anti-
histamines can be helpful.

Clinical signs of scabies are: Burrows commonly affecting sides of fingers, wrists and ankles.
Nodular burrows seen in genital area. Pruritic scabies rash also seen in axilla, umbilicus, buttock
and thighs. Skin is intensely itchy and may become eczematous and secondarily infected. Itching
may continue 2-3 weeks post treatment. If pruritis continues after 4 weeks review with consultant
dermatologist.

Refer to Appendix G for the rationale behind treatment protocols, methods of patient review and
discharge planning. Refer to Appendix H for teaching plan.

Page 20 of 33
5.1 Table 3 Guidelines For The Effective Treatment of Scabies

Action Rationale
All contacts need to be notified,
and a coordinated treatment
regimen instigated. This includes
close family members and sexual
contacts. It is vital that all contacts
are treated simultaneously and
effectively.
Contact tracing should go back 6
weeks.
Scabies can burrow into the skin
during skin-to-skin contact.
Symptoms of scabies may not
appear for up 4 weeks following
transmission, so potentially all
contacts may be affected.
Poor clearance or retransmission
of scabies is often due to failure
to treat all close contacts.
Before treatment it is important to
read the accompanying leaflet.
It is important to be aware of
potential hazards of the
treatment. Plus treatment times
and recommended application
may vary from product to product.
It is best to do the treatment in
the evening before going to bed.
Skin should be cool and dry,
avoid bathing before applying
cream.
This will ensure that the treatment
will be most effective and kept on
for the planned length of time.
The solution or cream should be
applied to the whole body from
the neck down, it is important to
include skin creases and
genitalia. Pay particular attention
to behind ears and knees, under
arms and breasts. The
cream/lotion should be applied
under toe and fingernails, which
need to be kept short; plus
between toes and to soles of feet.
It is vital that all areas are treated
effectively to avoid
retransmission.
Keeping fingernails short allows
effective treatment under nails
and reduces excoriations.
Flexural areas may harbour
residual mites if not treated
correctly, which will lead to
retransmission.
Ensure cream is reapplied after
washing hands or using the toilet.
Cream must be in place for the
prescribed time period to be
effective.
Leave cream on for 8 to 12 hours
as advised. Overnight is ideal.
This will ensure that the treatment
will be most effective and kept on
for the planned length of time.
Have a bath or shower and apply
bland moisturiser e.g. aqueous
cream or E45.
Residual cream/lotion should be
removed. Moisturising skin will
calm irritation.
All clothes worn for the previous
two days plus bed linen should be
washed and it is advised that the
home is vacuumed at the end of
treatment.
Mite may be transferred to
clothing, bedding etc. Normal
washing is sufficient.
Systematic laundering coinciding
with treatment will reduce the risk
of retransmission.
If there is a delay in treating any
contacts then if possible further
contact should be avoided until
treatment is complete.
This is vital to prevent
retransmission.
There is great importance in
thorough and effective contact
tracing.
Adapted from Hughes E & Van Onselen J (2001) Dermatology Nursing A Practical Guide. Churchill
Livingstone and Poulsom WJ (1999) Scabies Policy for Control in the Community Avon Health
Authority.

Page 21 of 33
5.2 Table 4 Extra Precautions to be taken in Cases of Crusted Scabies

Action Rationale
All actions on table 3 should be
followed in addition to these extra
precautions.
The basic principles of scabies
management should still be
followed to ensure effective
treatment.
In crusted scabies there are
thousands of mites and therefore
may be resistant to treatment.
Isolate the affected individual in a
single room.
Crusted scabies is highly
infectious so isolation is
necessary to avoid spread of
infection.
Establish which nurses, carers
and residents have had contact.
Instigate treatment.
If the patient receives input from
nurses or carers, or is in a
residential/nursing home, then the
potential number of contacts is
much greater. See action plan
outlined below (Table 5).
Use disposable gloves and
aprons.
Bag laundry as infected linen.
To prevent spread and
transmission of scabies.
Daily damp dust and vacuum the
room.
Mites are spread in large
numbers into the environment.
Discard creams/ointments
previously used by patient.
There is the potential that mites
could survive in the cream and
reinfect the patient.
Adapted from Hughes E & Van Onselen J (2001) Dermatology Nursing A Practical Guide Churchill
Livingstone.

5.3 Table 5 Action Plan -To Effectively Manage One or More Cases of
Scabies in a Nursing/Residential Home

Action Plan
Nominate one person who will coordinate the treatment plan, trace contacts,
keep individuals informed, and Monitor the response to treatment and
coordinate with the infection control department.
Clearly identify the source of the scabies. Is it from within the home or due to
a transfer in or new resident? Has the patient attended any appointments
outside the home? Do any of the staff work in other homes?
Check all staff and residents for signs of scabies.
Decide if isolation is necessary. Is it crusted scabies? If so follow guidelines
above.
Trace contacts generally treat all staff that have had skin-to-skin contact,
the individuals who this staffs have nursed, and the infected persons family
with whom they have had contact. Staff families are not usually treated unless
they are the infected case.
Instigate treatment as outlined previously.
Ensure the infected residents creams and ointments are discarded in case
they are harbouring mites.
All residents should have their own towels.
The need for careful hand washing should be reiterated to all staff.
Laundering and cleaning as outlined previously should be carried out.
Adapted from the directives in Poulsom WJ (1999) Scabies-Policy for Control in Nursing
&Residential Homes Control of Infections Unit Avon Heath Authority.

Page 22 of 33
5.4 Appendix G
Rationale for treatment and management of scabies

Action Rationale
Carry out a holistic assessment. A holistic assessment, will assist in
planning a treatment regimen, it allows
social and environmental factors to be
taken into account.
Assess and record skin condition, note
signs of infestation. Record treatment used
to date, plus that of family members and
contacts.
It is vital to have a clear assessment of
skin recorded so that comparative
judgments can be made. Signs of burrows
will indicate scabies is still present, rather
than a residual pruritis, which may last for
2-3 weeks. Knowing previous treatments is
important, as a maximum of weekly
treatments for 3 weeks should not be
exceeded. Also some scabicides are
thought to be more effective.
negotiate achievable goals for treatment;
the patients physical ability and
motivation need to be taken into account. It
is useful to ascertain if external help will be
needed to follow treatment through e.g.
district nurse, home help or health visitor.
Agreed treatment protocols are essential in
education to enable an understanding of
what scabies is and how it can be
effectively treated. (See table 3).
Page 23 of 33
Appendix G
Rationale for treatment and management of scabies

Action Rationale.
Treat with Malathion or Permethrin
following guidelines strictly.
There are three treatments available:
Quellada M (aqueous Malathion 0.5%)
Derbac M (aqueous Malathion 0.5%)
Lyclear Dermal Cream (Permethrin 5%)
Derbac M is the only one suitable for
pregnant women. Permethrin is thought to
be the most effective, and therefore may
be the treatment of choice.
(11)
Guidelines
and the rationale behind them are set out
in table 3.
Repeat initial treatment after 10 days. For effective treatment as eggs may have
been untreated on initial treatment.
In crusted scabies follow extra precautions In crusted scabies there are thousands of
mites, so transmission is easier and it may
be difficult to treat. (See table 4).
Be meticulous in the tracing of contacts. Poor clearance or retransmission of
scabies is often due to failure to treat all
close contacts.
Instigate the use of emollients, topical
steroids and antihistamines.
To maintain skin integrity and reduce
pruritis.


Action Rationale
Review patients at 7 10 days after initial
visit/treatment.
Observe for signs of infestation still
present. Provide support and
encouragement that clearance will be
achieved and pruritis will subside.
each visit.
To record response to treatment, look for
clinical signs of scabies, to monitor
residual pruritis and observe for potential
secondary infection.
Verbally assess if family members or
contacts have had a good response to
treatment.
To assess the level of clearance and to be
aware of the potential of retransmission.
(See table 3)
and contactable.

Page 24 of 33
6.0

hand and foot eczema. (Adult)

Holistic assessment and history taken. Skin
assessed, extent of affected

. Treatment regimen
following agreed
protocols. Incorporating
the core plan of care.

Presentation
of condition.

Review at 4-8 weeks

Second line treatment, to
be started if poor response
noted by week 4 -8.

Dry, scaling
thickened and
cracking.

Use a potent/ very
potent topical steroid in
an ointment base.
Use cotton gloves when
able or tubifast to feet.
Advocate greasy
moisturisers if tolerated,
see Table 1.
Treat cracks with either
super glue to clean
cracks or hydrocolloid
dressing.

Try polythene occlusion with
emollient and topical steroid
for 1week max. Then
reassess, consider trying
alternative potent topical
steroid.
Be cautious about occlusion if
there are numerous cracks,
which have potential local
infection. Consider Haelan
tape to cracks

Hyperkeratotic
or lichenified.
Use potent topical
steroid and advocate
greasy moisturisers
(table 1). Try local
occlusion with
hydrocolloid or paste
bandages.
Consider keratolytics under
polythene occlusion to
hyperkeratotic areas.
Lichenified areas may be
slow to respond so continue
with initial treatments.

Weepy,
pruritic or
pompholyx
appearance.

Use KMnO4 as
compress (see advice
sheet). Use potent
topical steroid in cream
form, consider
combination with an anti
bacterial, see table 2.
Use cotton gloves and a
tolerated emollient.

Try modified wet wraps or
paraffin dressings as
appropriate. Recommend oral
antihistamines particularly at
night time. Observe for signs
of secondary infection.

Core plan of care.
assessment and is a
planned teaching
program the
implementation of this
provides support and
guidance, enabling the
patient to understand
recognize the most
The educative program
will emphasize the
importance of avoiding
astringent substances
such as soaps and
shampoos.
recommended, in
addition to an oil
additive to bath/wash
water. Skin should be
moisturised at least 2/3
times daily or whenever
skin is dry All topical
steroid applications
should be used in
conjunction with
emollients. See table 1.
for further details.

Acutely
erythematous
and pruritic.

Use potent topical/very
potent steroid, cotton
gloves and a tolerated
emollient. Creams may
be more cooling.
Recommend
antihistamines and
elevation.

Consider polythene
occlusion.

In hand eczema advice re: avoidance of irritants is vital, it is also important to identify if this is potentially a
contact dermatitis, in which case patch testing would be beneficial.
Moderate clearance should be noted by 8 10 weeks. If yes continue and modify treatment for discharge
around week 12-14. If not then referral to Secondary care may be required; this also remains an option if the
skin flares at any time.
Refer to Appendix I for the rationale behind treatment protocols, methods of patient review and discharge
planning. Refer to Appendix J for teaching plan.

Page 25 of 33
6.1 Appendix I
Rationale for the treatment and management of hand and foot eczema

Action Rationale
disease. Environmental factors such as
regular contact with certain substances
may be relevant.
Extent of eczema and present treatments
recorded.
motivation need to be taken onto account.
Page 26 of 33
Appendix I

Action Rationale
emollients.
can dry the skin. Advocating an effective
skin care regimen using emollients is the
essence of eczema management.
Washing with an emollient is a moisturizing
and cleansing experience.

The cleansing
action removes dead skin cells and
residual topical medicaments.
Emollients act to reduce loss of skin
moisture and help restore the lipid barrier
imbalance.

For the emollient to work as an
effective barrier it must be reapplied at
least 2-3 times daily, 4-5 times if possible.
The range of emollients is wide and varied
so the patient needs to be clearly advised
so that they can make an informed choice
of the one which suits them and their skin.
treatments.
the benefits of certain treatments. Tones
steroids can minimize potential side
effects.
All topical steroid applications should be
used in conjunction with emollients. Where
possible tubifast coverings or cotton gloves
are recommended.
Using a combination of topical steroids and
emollients works very effectively for the
treatment of eczema. Topical steroids are
more rapidly absorbed when applied to
well moisturised skin. The ideal is to apply
the moisturiser 20 minutes prior to steroid
application
.
Tubifast coverings/cotton
gloves hold creams and ointments in
place, providing mild occlusion and can
prevent the individual harming their skin if
they scratch.
eczema.
Topical steroids suppress various
systematic components of the
inflammatory reaction. Topical steroids can
be combined with antibacterial and
antifungal agents. Vehicle choice can be
important, for instance cream can be
cooling on a hot erythematous skin.
Page 27 of 33
Appendix I

Action Rationale
Potent topical steroids are used and their
progress and usage are monitored
carefully.
Palms and soles have a thick epidermis,
which may reduce percutaneous
absorption of topical steroid. Potent topical
steroids can be used in these areas, often
for longer periods than elsewhere. It is
important to regularly review a patient
using a potent topical steroid, so that as
skin improves a step down to a moderate
then mild potency steroid can be made to
limit the long - term side effects, however
with correct usage, these side effects can
be kept to a minimum.
Patient education should include the
correct usage of topical steroids.
Generally people are concerned about
using topical steroids. It is important to
allay these fears with some clear facts and
guidelines that can be followed.
Reassuring the patient about these issues
can improve patient compliance and
ensure correct usage. Although overuse
can be a problem so can under use. It is
better that the correct quantities are used
for a shorter length of time, than too little
steroid over a long length of time with
frequent flares.
Treat cracks with super glue or duoderm
extra thin.
The cracks on hands and feet can be very
painful and have the potential for local
infection. A clean split or crack can be
sealed with superglue, thus reducing pain
and regaining skin integrity. Duoderm is a
hydrocolloid and provides an ideal
environment for wound healing as well as
the provision of a comfortable waterproof
protection for multiple cracks. Haelan tape
is a waterproof tape impregnated with a
potent topical steroid and can be used to
cracks,12 out of 24 hours.
Using paste bandages. These are helpful in the management of
excoriated, inflamed and lichenified
eczema. They are occlusive and offer
similar benefits to the wet wraps. There are
a variety of paste bandages available; the
choice depends on skin presentation and
patient tolerance.
Using polythene occlusion to hands and
feet.
Occlusion concentrates the effects of the
moisturiser and topical steroid, by
improving percutaneous absorption. It is
also a useful way of softening areas of
hyperkeratosis.
Using potassium permanganate (KMN04)
to weepy areas.
This is an astringent oxidizer, which is
used for its cleansing/antiseptic effects and
for its drying effects on weepy skin. It can
be an irritant and care must be taken to
dilute it and use correctly.

Page 28 of 33
Appendix I

Action Rationale
Using wet wraps or paraffin gauze
dressings.
Often used to control itch scratch cycle.
They are not suitable for infected eczema.
They involve applying a warm, moist
tubifast covering over skin treated with
emollient and a mild topical steroid. This
creates a cooling effect through
evaporation, rehydration via emollients,
protection from scratching, allowing
excoriations to heal and improved steroid
absorption. If there are multiple raw areas
then multilayered paraffin gauze may be
required to provide comfort and allow
healing to occur.
Recommending oral antihistamines. These can be useful short term to relieve
pruritis and may help to break an itch
scratch cycle, particularly if scratching is
occurring in the sleep. Depending on
choice they can have a sedative effect.
Observe for signs of secondary infection. There are many topical agents available
that have antimicrobial properties. These
may be useful in the management of
localized infection, however if there is
generalized infection then systemic
antibiotics may be necessary. A moist skin
swab should be taken to clarify antibiotic
sensitivity.
It is vital to be aware of the potential of
viral and fungal infections. (See table 6).
Using occlusion to thicker lichenified areas. Occlusion concentrates the effects of the
hyperkeratosis.

Page 29 of 33
Appendix I


Action Rationale.
clearance may take 12 weeks or more, if
morale is poor, compliance may also
suffer.
Assess and record the skins appearance
at each visit.
To monitor the response to treatment and
to make modifications to treatment plan to
meet changing patient needs.
Observe inflammation, weeping or other
signs of infection.
and contactable.

Page 30 of 33
7.0 TABLE 1
Emollients This includes some of the commonly used emollients,
however there are others available.

Criteria for choice Emollients
listed from light creams to greasy ointments
Aqueous cream- use as soap substitute only
E45 cream*
Ultrabase
Aveeno cream
Easily applied, well tolerated.
Contain preservatives, so observe
for sensitivity to these. Creams
have a high water content so can
be cooling on hot erythematous
skin.
Cetraban.
Diprobase cream*
Oilatum cream*- now available in junior formulation
Unguentum M. *
Greasier creams providing an
effective barrier for moisture loss.
Easily applied and well tolerated.
Neutrogena dermatological cream.
Epaderm* P Thicker base, but still water soluble,
so can be used as soap substitute.
Not so easy to apply, but offers
effective barrier without a wet/oily
feel.
Emulsifying ointment* P
Emollin 50/50 P
Diprobase ointment. P
Ointment base, easy to apply. May
need coverings as leave skin
greasy. Ideal for very dry and
hyperkeratotic areas. Can be
occlusive, causing a hot
uncomfortable feeling and may
cause folliculitis.
White soft paraffin/liquid paraffin 50/50. P
The asterick denotes emollients suitable for use as a soap substitute. This can also be used as a
moisturiser unless a lighter or greasier moisturiser is preferred. As a general rule the drier the
skin the greasier the moisturiser.

Patients using large amounts of emollient group containing paraffin (denoted by P)
should be advised regarding the associated fire risk and provided with the National
Patient Safety Agency advice leaflet found at the end of these guidelines.
Emollients with specific properties
Antibacterial- Dermol 500 lotion* and dermol cream* useful in infected/excoriated eczema and
MRSA.
Containing urea, a hydrating agent, useful for scaly conditions. May cause stinging. - Aquadrate,
Calmurid or Eucerin. Balneum Plus contains urea & lauromacrogols that have a local antipruritic
action.
Bath Oils
Dermol 600 Bath Emollient
Emulsiderm Emollient also useful for descaling hyperkeratosis on scalp.
Oilatum Frangrance Free Bath Oil
Balneum (soya oil) and Balneum Plus Bath Oil- (anti-pruritic)

Reviewed 21.12.2007
Review due 21.12.2008
Page 31 of 33
7.1 TABLE 2
Topical Steroids Potencies

Mild Moderate Potent Very potent
Hydrocortisone 1%
(HC)
Betamethasone
valerate 0.025%
(Betnovate RD)
Betamethasone
valerate 0.1%
(Betnovate)
Clobetasol propionate
0.05% (Dermovate)
HC 1% + urea 10%
(Calmurid HC)
Clobetasone
butyrate 0.05%
(Eumovate)
Betamethasone
dipropionate 0.05%
+ salicylic acid 3%
(Diprosalic)
Clobetasol propionate
0.05% + neomycin
sulphate 0.5% + nystatin
100000 units/g
(Dermovate NN)
HC 0.25% +
crotamiton 10%
(Eurax HC)
Clobetasone
butyrate 0.05% +
oxytetracycline 3%
+nystatin100000units
per/g (Trimovate)
Flucinolone
acetonide 0.025%
(Synalar)

HC 0.5% & Coal tar
extract 5% (Alphosyl
HC)
Desoximethasone
0.05% (Stiedex LP)
Fluocinonide 0.05%
(Metosyn)

HC 1% +
oxytetracycline 3%
(Terra-Cortril)
Mometasone furoate
0.1% (Elocon)

HC 1% + miconazole
nitrate 2%
(Daktacort)
Betamethasone
valerate 0.1% +
fusidic acid %
(Fucibet)

HC 1% + fusidic acid
2% (Fucidin H)
Hydrocortisone
butyrate 0.1%
+chlorquaninaldol
3% (Locoid C)

Page 32 of 33
8.0 Application of Emollients (moisturisers) Advice Sheet for
professionals/patients/carers

8.1 Apply directly to the skin.

8.2 Always apply in a downward motion in the direction of the hair growth.

8.3 Avoid vigorous rubbing which may cause plugging of the hair follicle and then
infection.

8.4 Always apply after a bath/ shower.

8.5 Do not stop once the condition is controlled. Emollients will help to prevent future
exacerbations.

8.6 Apply moisturisers as frequently as possible but at least 2-3 times daily.

8.7 Always try to reapply moisturiser to hands after they have been in contact with
water.

8.8 Apply the moisturiser in amounts that will cover the skin thoroughly and if you have
time, allow them to soak in naturally.

8.9 If you feel the moisturiser you are using does not suit you, please contact me and
we can alter it sooner rather than later. Remember, a good moisturiser is one
which you will use frequently!!!

Val Anderson
Dermatology Nurse
South Gloucestershire PCT
Page 33 of 33
9.0 Audit Tool

These guidelines will be evaluates through the number of annual referrals from
primary care health professionals to the dermatology nurse service.

In addition the usefulness of these guidelines will be audited via annual
questionnaires to be distributed to HVs, PNs and DNs within South Gloucestershire
by the Dermatology Nurse.

10.0 Equality Impact assessment these guidelines should not impact on any
minority or vulnerable groups

11.0 References

British National Formulary (2007) Section 13.5.2.

Chaffman, M (1999) Topical Corticosteriods : A review of Properties and Principles in
Therapeutic use. Nurse Practitioner Forum (10) 2 pp 95-105.

Cooper, P; Clark, M; Bale, S (2007) Best Practice Statement: Care of the Older
Persons Skin.

Ersser, S; Maguire, S; Nicol, N; Penzer, R; Peters, J (2007) A Best Practice
Statement for Emollient Therapy Dermatological Nursing Vol 6; Issue 3.

Griffiths, C E and H L Richards Psychological Influences in Psoriasis. Clinical and
Experiment Dermatology 2001.26: pp 338-342.

Hobden, A (2006) Strategies to promote concordance within consultations. British
Journal of Community Nursing, 11(7) 286-289.

Hughes, E and Van Onselen, J (2001) Dermatology Nursing, a Practical Guide
Edinburgh. Churchill Livingstone Press.

Lee, M; Marks, R (1998) The role of Corticosteroids in dermatology Australian
Prescriber (21) 1.

Richard, C. The Effects of Psoriasis and its Treatment: part 1. Nursing Times, 1995.
91(4) : pp 38-39.

Richards, H L, et al, Patients with psoriasis and their compliance with medication.
Journal of Amercian Academic Dermatology, 1999. 41(4) : pp 581-583.

NICE Guidelines : Management of Childhood Atopic Eczema.

12.0 Bibliography

Buchanan P and Courtenay M (2006) Prescribing in Dermatology Cambridge.
Cambridge University Press.

Ashton, R and Leppard, B (2005) Differential Diagnosis in Dermatology Oxon,
Radcliffe Publishing Ltd.

Kennedy, C and Mitchell, T (206) Your Questions Answered: Common Skin
Disorders London. Churchill Livingstone.

13.0 National Patient Safety Agency Fire Hazard leaflet

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