Available topical therapies [link]
Anti-inflammatory treatments [link]
Other topical immunosuppressants [link]
Topical treatments for psoriasis [link]
Keratolytic agents [link]
Adverse reactions to topical treatments [link]
Other modalities of treatment [link]
all substances applied to the skin are absorbed to some extent and it is important to remember that children have thinner skin and a greater body surface area to weight ratio compared to adults so care should be exercised, especially in premature babies, when applying a product over the whole body e.g. topical corticosteroids.
Treatments are available as creams, ointments, gels, pastes, lotions, paints, sprays, mousses, scalp preparations, soaks, and impregnated tapes.
Available topical therapies
( see Chapter 18)
( see Chapter 2)
• Calcineurin inhibitors.
• Non-steroid anti-inflammatory medication.
• Doxepin (may cause drowsiness).
• Antihistamines (may cause allergic contact dermatitis).
Treatments for psoriasis
• Vitamin D analogues.
• Salicylic acid.
• Vitamin A analogues.
• Salicylic acid – softens keratin. Available in various strengths. Avoid in those under one year and preparations greater than 12.5–26% in children. (Weaker preparations of 2–5% can be used to de-scale scalps.)
• 4% glutaraldehyde soaks.
• Podophyllin preparations (caution – highly neurotoxic if taken orally).
Bases act as carriers for active ingredients and may alter drug bio-availability. Different forms of skin treatments are available dependant upon the base used.
Useful on wet or delicate sites. Water-based and contain preservative chemicals to prevent colonizing microbes. In general, the ‘thinner’ the cream, the higher the water and preservative content. Preservatives can irritate or sting inflamed or sensitive skin and occasionally cause allergic contact dermatitis.
Better for very inflamed and dry skin e.g. eczema. Grease-based so better hydration for dry skin. Contain fewer preservative chemicals and are therefore less irritant but messy to use and may cause folliculitis, particularly under occlusive dressings.
Used predominantly for the scalp. Usually in an alcohol base which can cause stinging or irritation.
Useful for the scalp, especially if there is marked inflammation, weeping or erosions when alcohol-based lotions (some gels are also alcohol-based) can cause significant local discomfort or irritation.
• Foams and mousses mainly available as scalp preparations.
• Soaking solutions e.g. potassium permanganate soaks 1/10,000 (pale pink colour) for infected dermatoses or to clean ulcerated areas.
• Paints e.g. for fungal nail problems.
Topical corticosteroids (TCS)
* NICE Guidelines for childhood atopic eczema
For full recommendations on TCS usage for atopic eczema see NICE guidelines versions including the quick reference guide available free from www.nice.org.uk/CG057
Three major properties:
• Anti-inflammatory and immunosuppressive.
• Vasoconstriction: a test of which is used to determine the potency of a particular TCS formulation.
• Reduce cell turnover: long-term use, especially of very potent TCS may lead to reduced fibroblast production of collagen causing skin thinning (epidermal and dermal atrophy) and if not discontinued then ultimately striae.
Note: TCS use causes considerable anxiety among parents because of side effects and under-treatment is common. ‘Thinning’ of the skin is rarely seen with judicious use. It is important to explain this verbally to parents and emphasize it with written explanation.
Appropriate steroid quantities:
Table 3.1 Finger tip unit usage
1 FTU = the quantity of steroid squeezed from a standard (5mm nozzle) tube in a line from the distal crease to the tip of the index finger.
1 FTU should be used to treat an area of skin equivalent to twice the flat area of that same adult hand with the fingers together.
Two FTUs weigh approximately 1g.
TCS are divided in to four groups depending on potency: mild moderate, potent and super-potent (Table 3.2).
Table 3.2 Approximate guide to appropriate quantities of topical steroids
Age of child
Area of skin (FTU application)
Head & neck
Note: potency is not the same as strength. Strength is measured in percentages and this does not compare with potency e.g. 0.1% betamethasone valerate is potent compared with 1% hydrocortisone which is of weak potency.
topical corticosteroid preparations combined with other active ingredients are available. These include antiseptics, antibiotics, antifungals, antipruritic and keratolytic agents (Table 3.3).
Table 3.3 Topical corticosteroid preparations
Steroid + antiseptic
Steroid + antibiotic
Steroid + antifungal
Steroid + other
Steroid scalp prep
Other / comment
Vioform HC (clioquinol)
Calmurid HC (urea)
Eurax HC (crotamiton)
Clobetasone butyrate Eumovate
Fucibet (fusidic acid)
Diprosalic (salicylic acid)
Betnovate scalp lotion
Diprosalic (salicylic acid)
Dilutions available for plain steroid
(1 in 4 &1 in 10)
Synalar C (clioquinol)
Synalar N (neomycin)
Dilutions available for plain steroid
(1 in 4 &1 in 10)
Hydrocortisone butyrate (Locoid)
Locoid C (chlorquinaldol)
Elocon® scalp lotion
Topical corticosteroid combination products
TCS can be used short term (up to two weeks) in combination with antibacterial agents where skin infection is associated with significant eczematization or inflammation e.g. eczematized scabies, impetiginized eczema.
Avoid using where viral infection is suspected to be the predominant problem e.g. herpetic or varicella infection.
Which steroid to use?
It is important to be aware that occasionally contact sensitization to either a topical steroid or an excipient in the cream or ointment may occur. If reactions are suspected referral to a dermatologist for contact allergy (patch) testing ( see page [link]) is appropriate. Remember that creams are more likely to produce contact reactions (both irritant and allergic) than ointments.
Which corticosteroid is most appropriate to use will depend on:
• Body site
• Severity of inflammation
• Previous steroid usage and response
• Certain body sites such as face, neck flexures and genital areas are more prone to thinning with repeated use of TCS, particularly potent and super potent preparations and these should not generally be prescribed for children without specialist dermatological advice (Box 3.2).
• Whenever possible use weak preparations in these sites. If potent TCS are required for severe inflammation at these sites, use should be limited to a period of a few days except under specialist dermatological supervision e.g. for genital conditions such as lichen sclerosis, lichen planus or ulcerative bullous disorders where inflammation is severe and/or may lead to scarring, atrophy or ulceration.
• Avoid anything other than weak TCS in the peri-ocular area. Eyelid skin is very thin and TCS are easily absorbed increasing the risk of atrophy, cataract and glaucoma.
• At hair-bearing sites such as scalp, lotions or mousses are often easier to use but if inflammation is severe, a gel or ointment may be least irritant.
• Around and on the nail bed, lotion application may be helpful, sometimes with occlusion ( see page [link]).
Severity of inflammation
• For mild inflammation: use a weak TCS taking note that emollient therapy alone may be sufficient e.g. mild atopic eczema.
• For moderate inflammation: use a moderate potency TCS and reduce the strength as symptoms and inflammation settle.
• For severe inflammation: short-term use of a potent TCS (only up to seven days without dermatological advice) is appropriate for rapid relief of symptoms which improves patient morale, sleep and treatment adherence. Reduce frequency and/or potency as the inflammation settles.
• For very severe inflammation: super potent TCS are appropriate for conditions unresponsive to less potent steroid therapy e.g. lichen sclerosis, morphoea. They are safer for sites where the epidermis is very thick e.g. palms and soles. They should not be used in children without specialist dermatological supervision.
• TCS potency may need to be increased if a condition fails to settle.
However, before doing so ensure that:
• There is appropriate use of other therapies for the condition being treated e.g. emollients in eczema, antimicrobial agents for infection.
• There is appropriate adherence to previous treatments used.
• Quantity used is appropriate – FTU quantities help.
• The diagnosis is correct. You may be missing other conditions such as scabies in eczematized skin or contact allergy.
• In young infants and children, avoid potent steroids if possible (Box 3.2).
• At puberty the risk of stretch marks/striae increases significantly so take extra care if TCS are used at sites prone to growth-related striae.
Frequency of topical corticosteroid use
• Most TCS are recommended once or twice daily. However as inflammation settles, frequency of use can be reduced.
• Intermittent use of potent TCS reduces the risk of local and systemic side effects.
Duration of use depends on:
• Condition being treated.
• Severity of inflammation.
• Degree of lichenification/thickening of the skin.
• Adherence to therapy.
• Site – avoid longer-term use at delicate sites.
For chronic conditions:
a longer course may be necessary (one to three months or more) particularly if considerable lichenification from chronic scratching. Reduce potency and frequency of use as soon as possible.
In inflamed areas of eczema continue use of a TCS for two days after the redness has disappeared to prevent a flare (NICE Guidelines).
Topical corticosteroid under occlusion
Using TCS under occlusion e.g. with local dressings, bandages or stockingette garments increases skin absorption thus increasing the risk of topical and systemic side effects (equivalent to using a more potent preparation). It is useful in sites where TCS is often washed or rubbed off and it reduces the frequency of steroid application. Can be used to treat:
• Localized areas of chronic dermatitis to switch off scratching.
• Inflammatory nail diseases.
• To flatten hypertrophic scars.
• To treat painful fissures e.g. on digits or feet.
A tape preparation impregnated with steroid is available on prescription.
Note: TCS used over a wide area under stockingette bandages or garments for longer than a week increases the risk of systemic absorption and Hypothalamic-Pituitary-Adrenal (HPA) axis suppression.
These block the cytokine reaction triggered by inflammatory T cells.
Two different preparations are currently available:
• Pimecrolimus (Elidel®) – 1% cream.
• Tacrolimus (Protopic®) – 0.03% and 0.1% ointment.
A National Eczema Society written information sheet is available.
Use of calcineurin inhibitors
• Licensed from two years and above (0.1% tacrolimus is licensed from 12 years) in atopic dermatitis.
• Use in quantities similar to TCS.
• All sites (best for face and neck) – no atrophy.
• Twice daily reducing to once daily with improvement.
• Discontinue if eczema clears (tacrolimus is now licensed for twice-weekly use for 12 months for long-term prevention of eczema flares).
• Give advice on sun avoidance and sun protection.
• Stinging, soreness, burning.
• Acne and folliculitis.
• Skin sensitivity to heat/cold.
• Skin infection – particularly viral e.g. HSV.
Current NICE recommendations for calcineurin inhibitor use
• Not recommended for mild atopic dermatitis or as first-line treatment for any severity.
• Both are recommended (pimecrolimus for face only) for moderate or severe atopic dermatitis where there is a serious risk of adverse effects from TCS use.
• Treatment should only be initiated by physicians with a special interest/experience in dermatology.
Available from www.nice.org.uk
Coal tar has anti-inflammatory and antiscaling properties. Crude coal tar is available in paraffin base (coal tar BP). Cleaner proprietary preparations are more practicable for home use. Tar baths, shampoos and impregnated bandages are also available. Side effects include irritation, folliculitis and contact allergy. Tar preparations can be useful in some forms of eczema.
Dithranol decreases the rate of keratinocyte differentiation thus reducing epidermal thickening and scaling. It is available as a paste (sometimes mixed with other active ingredients such as salicylic acid), ointment and cream. It can be used:
• Short contact – washed off after 10–60min.
• Long contact – wash off if irritation occurs.
Varying concentrations are available. Start with the lowest concentration and increase to a higher concentration every three days if tolerated.
To reduce burning apply to a small test area first with each new concentration prior to more widespread use.
• Burn-like skin irritation which can be severe.
• Staining – skin, hair and nails which fades over 1–2 weeks.
Apply with gloves taking care to avoid contact with normal skin surrounding lesions.
Vitamin D analogues
Calcipotriol, calcitriol and tacalcitol are available to treat plaque psoriasis; however only calcipotriol is licensed under 12 years (from six years).
• They do not stain unlike tar and dithranol but local irritation is not uncommon so they should be used with caution on face, genitals and flexures (see manufacturers’ recommendations).
• Occasional aggravation of psoriasis can occur.
• Hypercalcaemia may occur if used excessively.
Avoid in generalized pustular or erythrodermic psoriasis because of irritation and enhanced risk of hypercalcaemia.
These soften keratin and are used as anti-wart agents and to soften and de-scale hard, thickened skin (hyperkeratosis) on scalp, palms and soles. Salicylic acid is most commonly used, but urea preparations can also be helpful.
• Available in a number of proprietary and hospital manufactured preparations as pastes, ointments and lotions, often combined with other topical treatments e.g. corticosteroid, zinc or tar.
• Local skin irritation can occur.
• If used in young children, over wide areas or where the skin barrier is significantly impaired, systemic absorption can occur with the risk of salicylate toxicity.
• It should be avoided in infants under two years and used with caution and in small amounts only in those under six years.
Indicated for all dry and scaling skin disorders to hydrate, smooth and soothe the skin. Choice depends on the severity of the condition, site and patient preference. Apply in direction of hair growth to minimize follicular irritation and smooth in to facilitate absorption (rubbing hinders absorption).
Emollient preparations with antimicrobial agents are available. These are only appropriate if infection is present or is a frequent complication as anti-microbial may cause irritation and less commonly contact allergic reactions.
Emollient preparations available
• Bath oils.
• Shower gels.
• Vaporized spray.
Commonly used plain cream and ointment preparations in approximate order of thickness
aqueous cream frequently causes irritancy if used as a ‘leave on’ rather than a wash emollient.
Quantity of emollient to be used per week (Table 3.4)
For most conditions emollients should be applied all over the body to prevent skin dryness not just to actively involved areas e.g. in atopic eczema. It is essential to ensure that appropriate quantities are prescribed regularly to ensure adequate benefit and treatment compliance.
Table 3.4 Quantities of emollients recommended for generalized dry skin conditions
Amount (g) per week
125 = ¼ large tub
250 = ½ large tub
500+ = 1+ large tub
Side effects of emollients
• Local irritation – more common with lotions and creams, and those preparations with antiseptics. Aqueous cream is cheap and therefore commonly used but is irritant in almost half of patients.
• Contact allergy – most commonly to added fragrances, preservatives, antimicrobials and sunscreens in creams.
• Follicular occlusion/folliculitis – more likely to occur with greasier emollients especially used under occlusion or in hot weather.
• Systemic allergy – e.g. to products applied to which the subject is allergic e.g. soya or nut containing products (rare).
Other hydrating agents
The stratum corneum contains natural water-retaining substances, including urea which can therefore be used to treat dry skin conditions and keratosis pilaris. It is found in a number of emollients and is occasionally used with other topical agents such as corticosteroids to enhance penetration. Can be used in high concentrations (such as 40%) to soften and remove nails provided that the surrounding skin is protected.
Sunscreens are used to protect skin from burning and ageing and in photo-aggravated and photo-induced skin diseases ( see Chapter 16) to prevent/reduce flares. Preparations contain substances that protect the skin against UVB (ultraviolet radiation with wavelength between 280 and 320nm) which can cause sunburn and UVA (ultraviolet radiation with wavelength between 320 and 400 nm) which penetrates the skin more deeply and causes long-term skin ageing. Sunscreens are available as creams, lotions, gels, and sprays.
The sun protection factor (SPF)
gives guidance on the degree of protection offered against UVB (SPF 30 is usually recommended). It indicates the multiple time of protection against burning compared with unprotected skin.
The star rating
(maximum 4 stars) gives guidance on the degree of protection against UVA.
Unfortunately the thickness of application used to provide guidance ratings is often far greater than quantities applied in everyday life.
No sunscreen blocks completely – clothes provide best protection.
The active ingredients in sunscreens include:
• Physical blocks – opaque materials that reflect light e.g. titanium dioxide and zinc oxide.
• Chemical blocks – organic chemical compounds which absorb light e.g. oxybenzone and cinnimates.
For optimum photoprotection, sunscreens should be applied liberally and frequently (two-hourly) and after bathing or swimming.
Adverse reactions may include:
• Irritant contact reaction – more likely to occur with products containing higher quantities of excipient additives/preservatives and therefore more frequent with creams than ointments. As the skin barrier improves creams are better tolerated. On areas of broken skin due to excoriation, erosion etc., alcohol-containing preparations can cause significant stinging e.g. in lotion preparations. Switching to an ointment-based preparation can help.
• Allergic contact reaction – can occur due to added fragrances, preservatives, antimicrobials, or more rarely topical corticosteroids. Reactions to dressings and bandages may also occur e.g. due to colophony in elastoplast/adhesive dressings, or latex in bandages. Investigation: detected by patch tests ( see Chapter 2).
• Other local side effects
• atrophy, striae and telangiectasia – topical corticosteroids.
• infection risk – topical immunosuppressants.
• folliculitis – tar and emollients.
• burn-like reaction – dithranol.
• caustic burns – from inappropriate dilutions e.g. potassium permanganate solution, salicylic acid preparations.
• temporary skin staining – dithranol, potassium permanganate.
• pressure effects – of inappropriate/incorrect bandaging.
• Systemic side effects
• HPA axis suppression after significant or long-term use of potent topical corticosteroids which may affect growth (rare).
• Anaphylaxis e.g. to latex in sensitized individuals.
• Salicylism from topical salicylates (do not use under two years and use only small amounts under six years).
• Increased absorption of any drug may occur in prems and neonates and those with erythroderma (≥90% generalized redness).
( See also Chapter 23)
Medicated dressings and bandages
These are occlusive and used for protection, support, to aid healing or for treatment such as hydration of the skin. A wide variety are available:
• Dry bandages – with or without elastication, gauzes, tubular bandages, garment type occlusive dressings.
• Wet-wrap dressings and garments (figure. 3.2).
• Non-adhesive dressings – numerous types.
• Impregnated bandages – usually with zinc oxide paste and other excipients such as tar, ichthammol or antimicrobial agent (figure. 3.3).
• For localized dermatoses where secondary lichenification has occurred due to chronic scratching, e.g. eczema, to switch off the itch–scratch cycle.
• When local trauma (intentional or non-intentional) is exacerbating or inducing a skin condition.
• To reduce the need for frequent treatment applicatons.
• To improve compliance.
• To increase the efficacy of topical therapy.
• For the compressive effect e.g. to improve venous return.
Correct usage requires appropriate training and they should be avoided if skin infection is suspected or in those with a risk of vascular compromise.
Medicated bandages may contain:
Side effects include:
• Local skin irritation including folliculitis.
• Contact allergy – to the bandage material or impregnated medication.
• Vascular compromise – if applied too tightly or in patients with impaired circulation.
For a full description of all available dressings see the British National Formulary for Children.
Injection of botulinum toxin into the skin to reduce hyperhidrosis (excessive sweating; see page [link]). Expensive and only available in some NHS units. Can cause temporary localized weakness and the effect lasts only a few months but can be repeated. Not licensed for use under 16 years.
Important aspect of care for facial conditions in particular. The British Red Cross runs a free service in the UK and some other countries with referral through the local dermatology department in most cases. Various tinted creams are available on NHS prescription to help camouflage conditions such as acne or port-wine stains. Camouflage is often used alongside laser treatment until such time as benefit occurs.
Electrolysis is a method of permanent hair removal. Only available on the NHS in some hospitals. An electrical thin metal probe is slid into the hair follicle avoiding puncture of the skin to deliver a charge causing local damage to the hair follicle. Treatment can be painful and time-consuming. There is a risk of scarring, post-inflammatory pigmentary change and secondary infection.
A non-invasive method of propelling a charged substance transdermally using a small electrical charge and a liquid such as tap water, with or without an active agent such as an anticholinergic drug. The charge alters permeability of the skin to the active ingredient. Main use is for treament of hyperhidrosis ( see page [link]) but benefit is only temporary and maintenance treatment is required e.g. every six weeks. Only available in some hospitals but if successful, home machines (using tap water) can be purchased. Treatment is contraindicated in pregnancy and for those with metal orthopaedic implants or a pacemaker.
Most commonly corticosteroids to treat keloid scars or alopecia areata. May cause local atrophy which usually recovers with time.
High pressure spray injection as alternative to using needles, mainly used for intralesional corticosteroids.
Wigs ( see page [link])
A variety of lasers are used to treat skin conditions and all require specialist training and knowledge. Most young children require general anaesthesia although older children may cope with local anaesthesia. The effectiveness of therapy is often hightly variable and it is important not to raise the child and parents’ expectations too much. They must also be informed of any potential side effects (pain, scarring, hyper/hypopigmentation, recurrence of lesions).
Some lasers are used for several different functions and there are too many on the market to comment on them all. The following are currently found to be useful:
• Argon pumped tunable dye laser for vascular lesions e.g. port-wine stains.
• Flashlamp excitable dye (pulse dye) has less side effects and is currently the best for superficial vascular lesions.
• Carbon dioxide for resurfacing or removing small tumours.
• Q-switched yittrium aluminium garnet (YAG) for some pigmented lesions such as lentigines and naevus of Ota.
• Alexandrite and Q-switched ruby lasers used for pigmented lesions and tattoo removal.
• Hair removal lasers are only useful for dark hair and the effect is not permanent – regular treatment every few weeks is usually required.
Phototherapy can be used to treat a large number of skin diseases including psoriasis, eczema, acne vulgaris, vitiligo and cutaneous T-cell lymphomas. However, it is not used in very young children because of practical difficulties and even in older children it should be used with caution because of the potential for increased risk of skin cancer in later life.
It encompasses a wide range of treatments using various wavelengths of ultraviolet light in the UVA to UVB spectrum (290–400nm). The most widely available are:
• Narrow wave band UVB or TL-01 (311nm) – currently the most often used.
• Broad band UVB (290–320nm) – used less often now.
• UVA (320–400nm); UVA-1 (>340nm) is not available in many centres.
• PUVA (Psoralens – photosensitizing drugs with UVA light) is rarely used in children except in those with skin type III–VI to treat vitiligo.
UVB phototherapy is often used in combination with topical treatments such as emollients, topical corticosteroids, tar preparations (Goeckerman regime) or dithranol (Ingram regimen).
Phototherapy should only be initiated and undertaken in specialist centres with staff trained in its use. Records should be kept of the number of treatments given and the total joules used.
The use of a phototoxic agent in combination with a source of light to destroy abnormal areas of skin such as skin cancers. Rarely used in children.
Many systemic therapies are used in dermatology and are mentioned in specific sections throughout this book. Many are not licensed for use in children and should be used with caution.
The majority fall into the following categories:
• Antibiotics and other antimicrobial agents including antivirals and antifungals; for infections or as acne treatment.
• Anti-inflammatory agents.
• Antihistamines – mainly for urticaria and to combat itch.
• Antimalarials such as hydroxychloroquine for SLE.
• Agents to reduce hyperhidrosis (teenagers mainly) e.g. oxybutinin.
• Immunosuppressive therapy – including methotrexate, ciclosporin, azathioprine, mycophenylate mofetil (all mainly for eczema and psoriasis, less commonly SLE or other autoimmune disorders). Systemic corticosteroid therapy can be given orally or as pulsed IV methyl prednisolone e.g. in severe autoimmune disease.
• Sulphones such as dapsone (used mainly for immunobullous disorders).
• Retinoids e.g. isotretinion (for severe acne) and acitretin (for severe psoriasis and ichthyosis). These are both teratogenic and must be avoided in pregnancy.
• Biological agents (antitumour necrosis factor-alpha therapy): a few such as etanercept are now licensed to treat psoriasis and psoriatic arthropathy in children.
• Intravenous gammaglobulin for replacement in immunodeficiency syndromes. It has also been used in Kawasaki disease, dermatomyositis, and toxic epidermal necrolysis and others.