Unless you explain to the patient and relatives the underlying etiology of the disorder, the problem will recur. Bathing habits should be reviewed; the patient should be using a
mild bath bar with moisturizing ingredients. Showers are less drying than tub bathing. Spas and hot tubs should be discouraged. Emollients and medications must be applied immediately after toweling before the skin really dries if they are to be maximally effective. Explain the effect of dry heating sources, and encourage the use of a humidifier. Cold-water vaporizers are an inexpensive means of raising humidity, and they are portable and safe. A central humidifier attached to the furnace is ideal, but is a substantial expense. Small room humidifiers work well, but again they are expensive and have ongoing upkeep costs.
Corticoids will suppress inflammation but will not correct the underlying dryness. They should be reserved strictly for the inflamed or frankly eczematous lesions. You may use group VI or VII steroid creams for this purpose, and try to choose those with an emollient base. These products have enough potency to correct the inflammatory changes, and virtually no risk of secondary atrophy. They should be applied to the inflammatory lesions only, and should be followed immediately with a general application of moisturizer.
Lubricants are the real therapeutic mainstay for correcting dry skin. Two factors must be considered when recommending a lubricant: (1) it must correct the dryness, and (2) it must have enough patient acceptance that it will be used regularly. Two effective emollients are Original Formula Eucerin® cream and Cetaphil Moisturizing Cream®. These should be applied initially TID over any dermatitic sites that have just been treated with the topical corticoid. As areas of asteatosis improve, the topical steroid is gradually discontinued. Moisturizers must initially be applied in a general fashion two or three times daily and immediately after toweling. Once asteatosis is corrected, nightly application may be sufficient.
Several products are available OTC that contain either an a-hydroxy acid or urea as active ingredients. Both ingredients improve the water-holding capacity of the epidermis. These active agents have a definite long-term beneficial effect on the appearance and function of the epidermal surface.
Products are available OTC containing 5 to 10% lactic acid, and there is a cream preparation available by prescription with a 12% concentration. Because these products produce some burning or stinging when applied to open lesions, they are not well tolerated initially. They are best added as a single daily application under the general emollient after epidermal integrity has been restored.
Urea products are available OTC in 10 to 20% concentrations. These should be used with caution in the early stages of treatment, as their concomitant use can greatly enhance the percutaneous absorption of some topical steroids. They can be used in a fashion similar to the a-hydroxy acid preparations.
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