Severe chronic atopic eczema

author/source: DrB



A member has been in touch about his severe widespread chronic eczema. In particular his skin shows in many places marked lichenification (see above, left anterior lower leg) caused by his long term habitual scratching. I discussed with Dr Peter Norén the best advice we could give him.

Localised chronic eczema can be safely and effectively treated under medical supervision using gel dressings over applications of topical steroid. We have written about this previously, first in our handbook in the chapter on Conventional Treatment, and here in the article Three-in-one: the hydrocolloidal gel dressing.

When lichenification is as marked as in this case, the treatment programme needs to be more intensive. We therefore recommended the following regime, under medical supervision.

1. Without changing current treatment, use a hand tally counter to count daily scratching totals for one week, noting the circumstances and times of most scratching.

2. Make a plan for habit reversal, involving both specific and general measures: start habit reversal after the week of registration, and continue to use habit reversal as needed, for several weeks, until habitual scratching has stopped. Continue to use the hand tally counter to monitor progress.

3. After the week of registration start also optimised emollient treatment and topical Dermovate twice daily to the eczema, apart from the worst areas of lichenification: for these start applying extra-thin hydrocolloidal dressings over applications of Dermovate. For the first week reapply the dressings over a fresh application of Dermovate once daily. Then the same but every two days, for another week. Then, with progress, every three days for one week, then every four days for one week, continuing in this way for six weeks. NB: the frequency of changing the dressings needs to be adjusted so that the dressings are changed before any itch reappears.

4. Continue to apply Dermovate regularly beyond the Look Good Point, for a week or so, to ensure “hidden healing”. This will not require use of a dressing.

5. Because the eczema is so widespread, after the first week of registration also start taking oral prednisolone 25mg daily, for three days, then 20mg daily for three days, then 15mg daily for three days and so on until it is 5mg daily for three days, then stop.

5. Later treat acute flare-ups with 25mg of prednisolone daily for two days; then with progress, switch to using topical steroids as recommended using The Combined Approach.

Gel dressings act in place of emollient: they are effective moisturisers. Revert to using regular emollient as needed once the gel dressings are no longer being used.

Please contact us if you have questions about The Combined Approach to atopic eczema.