A deep dive into the dermis

On the topic of treatment

Many skin condition treatments contain topical steroids. While highly effective as treatments, the skin can become dependent. Topical Steroid Withdrawal (TSW) occurs when moderate or high-potency topical steroids that have been used for a prolonged period come to an end. A higher potency steroid is sometimes required to alleviate these symptoms, which are often more severe than the symptoms initially experienced, and a dependency cycle is created. Many people experience red, dark, burning and itchy skin.  

Pharmacy teams can advise customers to apply ice or a cool compress to the skin, recommend an antihistamine to relieve the redness and itch, pain relivers or non-fragranced emollients to soothe the skin. Furthermore, if customers come in to collect a prescription for a topical steroid cream, the pharmacy team can discuss the potential risks of TSW and ensure they have consulted all options. It is possible for people to see results on the smallest possible dose, or to alternate between nonsteroid and steroid medicine to avoid TSW in the long-term.  

Taming flare ups

Eczema, also known as dermatitis, is a chronic, non-contagious condition affecting one in five children and one in 10 adults in the UK. The cause of eczema is not completely known, however, it tends to run in families and is common among those who also experience hayfever or asthma. Atopic eczema, the most common type, is caused by gaps in the skin cells that allow bacteria, irritants and allergens to penetrate the epidermis. These gaps also lead to increased water loss, meaning drier skin.

Atopic eczema tends to have ‘active’ and ‘inactive’ periods. Known as ‘flare-ups’ the active periods are acknowledged to be triggered by certain irritants. “Skin with eczema is more liable to become red and inflamed on contact with substances that are known to irritate or cause an allergic reaction,” explains the National Eczema Society. These differ for each person, but common triggers are fragranced detergents, perfumed soaps, stress, weather or certain materials.

On white skin, these affect the creases of body joints like the back of the knees or insides of elbows, while in darker skin tones, the front of the knees and outside of elbows are commonly affected. The skin becomes reddened on white skin or darker brown, purple or grey on brown skin and becomes itchy, scaly or cracked.

Emollients (moisturisers) are often the first thing recommended to treat flare-ups. Customers need to consistently use an emollient to help their dry skin. Topical steroids are also often recommended, as well as sedating antihistamines to help customers sleep at night, but long-term use of both of these medicines should be assessed by a GP. Pharmacy teams can suggest paste bandages or wet wraps to relieve itchiness and prevent scratching. Avoiding known triggers is one of the most effective ways of preventing flare-ups, and sometimes allergen tests can be recommended if a customer cannot pinpoint what is sparking their eczema.

Scaled up

Psoriasis affects people with accelerated skin cell replacement, meaning they have an increased production of cells. “Usually, the skin replacement process takes 21-28 days, in people with psoriasis, this process is quickened and takes only a few days,” said a spokesperson from the Psoriasis Association. “While genetics and immune system issues are related, the precise role of genetics in psoriasis development is not fully understood.” This increased production of cells leads to patches of dry, scaly skin which appear in pink or red patches with white or silvery scales on white skin, and purple or dark brown patches with grey scales on brown or black skin.

Psoriasis can be treated with OTC products like topical creams and ointments, gels or shampoos, but depends completely on the severity of the psoriasis. Mild psoriasis benefits from applying emollients directly onto the skin to decrease water loss and cover the skin with a protective film, which also works to limit itching and scaling. Vitamin D analogue creams can be recommended for mild to moderate psoriasis. These creams are anti-inflammatory and decelerate the production of skin cells. Coal tar, another treatment option pharmacy team members can recommend, is one of the oldest remedies for psoriasis and relieves itchiness, scaling and inflammation. As it is a heavy, thick oil, customers should be warned that it can stain clothes and bedding.

If customers are not seeing improvements with these OTC treatments, they need to be referred to the pharmacist or GP.

Rock-a-bye baby

While some people develop skin conditions later on in life, some experience skin issues within their first few weeks. Seborrheic dermatitis, commonly known as cradle cap, is a common, non-contagious skin condition that affects infants usually between three weeks to 12 months. The condition forms over a baby’s scalp or forehead in yellowish, greasy scales and is caused by the overproduction of oil. This is thought to be due to the hormonal changes that occur during pregnancy which stimulate the infant’s oil glands, leading to overproduction.

Thankfully, it is a painless condition that disappears on its own after about six months. It doesn’t require treatment, but parents/caregivers can lightly massage an emollient onto the baby’s scalp to help loosen the scales, or gently brush the scalp with a soft brush before washing with baby shampoo to reduce the scales. It is important that shampoo is rinsed out thoroughly and no adult shampoo or oils are used. Pharmacy teams should also advise parents or caregivers not to pick the crusts as this can lead to infection. Unperfumed baby shampoos and gentle emollients should be recommended so as not to irritate the condition. If the condition spreads to other parts of the body or the scales look swollen, bleed or leak fluid, refer to the pharmacist.

Dig into dandruff

Another scalp condition is dandruff, which similarly to cradle cap, is not contagious and poses no real health threat apart from being uncomfortable and unpleasant. A common misconception is that dandruff is caused by poor hygiene, but it is in fact another impact of oil production on the scalp. Dandruff sufferers have a combination of a sensitive scalp, natural oils (sebum) and a scalp specific yeast-like fungus called Malassezia globosa which produces oleic acid. People with a sensitive scalp will react to this acid.  During puberty, hormone changes increase oil produced by the scalp, making this a common period for people to develop dandruff symptoms for the first time. It can also be brought on by stress, old age (hormone changes) and weather conditions. Dandruff is characterised by white or grey flakes on the head or shoulders, but itching, redness and a dry scalp are also indicative of the condition.

Luckily, dandruff can be treated in the pharmacy and many shampoos have been designed to target it. Shampoos with any one of the following ingredients will help alleviate dandruff: 

• Zinc pyrithione, which has antifungal properties
• Salicyclic acid, as it removes build-up
• Selenium sulphide, for severe cases, which contains an antifungal agent and should be rinsed out thoroughly to avoid discolouring the hair and scalp
• Ketoconazole, which kills dandruff-causing fungi
• Coal tar, or tar-based shampoos, as they slow down the rate at which skin cells die and flake off. These shampoos can make the scalp sensitive to sunlight
• Fluocinolone shampoos, known to reduce swelling, itching and flaking in severe cases.

Customers may need to alternate between medicated shampoos to maintain effectiveness. If symptoms are not improving or the scalp is red, swollen or symptoms have spread to the face or other body parts, refer the customer to the pharmacist.