What should I apply FIRST ? Emollient or Topical corticoteroid ?

Emollients and topical steroid creams are often prescribed by the doctors for inflammatory skin conditions especially eczema/dermatitis. Both products are useful for treating such skin conditions. They are like "peanut and butter" - perfect combination for a toasted bread. 

Goole searched image 

 Often, emollients comes in different formulations - ointment, emulsion (water in oil; oil in water) , cream, lotion etc. They are meant to be applied liberally on your skin to moisturise, thus hydrate your skin all the time. In addition, emollients can always act as protective barrier that prevent skin contact with irritants. Hence, you need to apply them to the affected area(s) as frequent as possible. Do not have to worry about overdoing! What emollient do is to keep your skin hydrated. 

Topical steroid, on the other hand, is prescribed for "flare-up". When your skin becomes inflamed ( reddened, swollen, blistered, thickened), topical steroid is really good in treating this. In fact, the prescriber always use topical steroid, starting at the lowest potency, to treat your eczema or dermatitis. 

Google searched image 

Here comes the question, both are prescribed together - which one should I apply first ? 

Emollient ? or Topical Steroid ? 

Google searched image 

It has been a long debate among healthcare professionals whether which one should be applied first - to have it best effect on the treatment. 

Some argued that you should apply emollient first - to hydrate your dry skin first. Then, you can apply steroid. This improves the absorption of topical steroid into your skin,thereby, increasing the effectiveness of treatment. 

Some argues that you should apply topical steroid first. This is because if you apply emollient first, you would have dilute the concentration of steroid, thus, reducing the effectiveness of treatment. 

I looked up several websites and articles, and here is what I got:- 

For those who have some dry skin conditions ( in which their skin are very dry, even exfoliate and become flaky), apply emollient first is important. Here is the suggestion - apply emollient liberally on your skin (especially those affected area) 20-30 minutes before you apply topical steroids (1)(2). 

When the skin is hydrated, it becomes easier for you to spot the angry/red are(s) which then you can apply topical steroid on them to reduce the inflammation. One more reason is that - applying emollients can remove the flakes that could then increase the absorption of topical steroid. (1) . However, make sure that the skin is not too slippery when apply topical steroids. 

Applying topical steroid first before emollient is mainly based on the fact that topical steroid may be diluted by emollient. Some proposed "emollient sandwich" model whereby applying emollient after topical steroid can provide an occlusive effect , therefore enhance the effect of topical steroid in treating "flare-up". (3)

In fact, there are a lot factors that affect the absorption of topical steroids into the skin including formulations of emollients and topical steroids (composition, particle size, lipid-water partition coefficient, ionisation, local effects) , skin condition ( hydration level, level of subcutaneous skin damage, anatomical site), reservoir effect, application dose ( concentration , amount) etc.

A guidelines suggested the application of emollient first owing to the fact that topical steroid may be more effective and reduction of the risk of steroid spreading to the unaffected area (healthy skin) if emollient is applied straight after the use of topical steroid.

Still, there is no clear cut evidence as in which one should be applied first. 

Summary 

1. Emollient should be applied first (to hydrate the skin) , then apply topical corticosteroid on the red/angry affected area (15-30 minutes after) , if possible.  (my personal view based on evidence I read).

(Most of time, you only need to use topical steroid for few times (Once daily, twice daily or as directed) for short term, while you always use emollient as frequent as you like )

2. Make sure you use emollient liberally (a few times daily as long as your skin is hydrated)

3. Only use topical steroid for "flare-up" - inflamed, red, itchy skin. Use appropriate amount (fingertip unit) [a guide table is provided below].And,  DO NOT use THINLY or SPARINGLY.

Table 3: Approximate number of adult finger tip units (FTU) of corticosteroid needed per application for children with eczema15 *

	3–6 months old	1–2 years old	3–5 years old	6–10 years old
One entire arm and hand	1	1.5	2	2.5
One entire leg and foot	1.5	2	3	4.5
Torso (front)	1	2	3	3.5
Back and buttocks	1.5	3	3.5	5
Face and neck	1	1.5	1.5	2

* Note that these values are a guide and will be influenced by the size of the child

Guidelines obtained from bpac article - Topical corticosteroids for childhood eczema: clearing up the confusion

References 

http://patient.info/health/moisturisers-emollients-for-eczema

http://www.mims.co.uk/article/591931/apply-emollients-topical-steroids

http://www.academia.edu/7368921/Topical_steroid_or_emollient_which_to_apply_first_A_critical_review_of_the_science_and_debate

http://www.bpac.org.nz/BPJ/2009/September/docs/bpj23_corticosteroids_pages8-13.pdf

http://www.bpac.org.nz/2016/topical-corticosteroids.aspx

Say NO to "Thinly" or "Sparingly" For Your Kid's Eczema Treatment

Say NO to thinly/sparingly for your kid's eczema treatment. 

 

Modified from Google search image 

Image obtained from Google search

Misconception about steroid has been rooted in some of our minds  for a long time. Patients are fear of steroid medicine , so do the health professionals. One of the common thing you hear when it comes to the use of topical steroid cream is to apply THINLY/SPARINGLY on the affected area.  Most of time, it results in treatment failure rather than treating the skin diseases such as eczema effectively. 

People become more concerned when it comes to treating eczema among children using topical steroid. We all know about the potential side effects of steroids could be scary such as skin thinning , depigmentation, irreversible striae or even worse, Cushing's syndrome due to the absorption of corticosteroid into blood stream. Inevitably, this may happen especially when you are using a highly potent steroid and apply the topical steroid on considerable large areas of your skin. 


Recently, dermatologists have called on health professionals especially pharmacists not to talk the patient into using the steroid cream/ointment sparingly or thinly. Correct use of topical steroid can effectively reduce "flare up" of dermatitis/eczema. 


Topical steroid is your kid's best friend in treating eczema. Encourage appropriate use. 

To be honest, the chance that patient are not treating their kids sufficiently are much higher than over-using topical steroid cream.


It's true that some  believe that it would be better to stay at the "safe" side by saying apply "thinly" . Rather safe than sorry, they said. Saying that, it might be not actually true.  Ue of these terms "sparingly" or "thinly" may encourage those parents who have steroid-phobia to apply too little topical steroid that fail to treat skin's "flare-up". 




We should not encourage patient to use topical steroids sparingly, it does not mean that we encourage patient to overuse topical steroids. 


Apply liberally on to the affected area as in the instructions with emollients should not be used either. The point is we should talk to patient and guide them on how to use topical steroids. Fingertip unit is a good way to guide them on the amount of topical steroid should be used. 


"Thinly" or "Sparingly" is very subjective among individuals. How "thinly" should "thinly" means? 


Some of our body part, such as face and genital area have more sensitive skin may be more sensitive to topical steroid treatment. For certain part of the body such as skin fold, flexures,  topical steroid could be applied thinly as directed by prescriber if it is for long term use. However, if it is for short term use to treat flare up. appropriate use should be encouraged and "thinly" term should be avoided, still. 

Starting from lowest potency of topical steroid, and step it up when required. That's true. 


However, do not fall into the percentage(%) "trap" stated on topical steroid medicine. It seems logic to think that 1% hydrocortisone is more potent than 0.05% clobetasol propionate. 

This is absolutely WRONG! In fact, o.o5% clobetasol propionate is about 600 times more potent than hydrocortisone! 

Therefore, do not self-judge the potency of steroid medicine by using the percentage. Ask your pharmacist or doctor about topical steroid if you are concerned. 




References

https://ajp.com.au/news/pharmacists-contributing-steroid-phobia/

http://www.bpac.org.nz/BPJ/2009/September/docs/bpj23_corticosteroids_pages8-13.pdf

http://www.bpac.org.nz/2016/childhood-eczema.aspx

http://www.bpac.org.nz/2016/topical-corticosteroids.aspx

http://www.academia.edu/7368921/Topical_steroid_or_emollient_which_to_apply_first_A_critical_review_of_the_science_and_debate

Worms - A deeper look into pinworms (threadworm)

Ever experience itchy bum during your childhood and your mum said that you must have worms in your tummy? And then you cry so hard because you just can't imagine there are worms living in your tummy?

Worms

There are some worms are parasitic who live in our guts such as tapeworm (usually found in uncooked meats), roundworm, hookworm, whipworm, pinworm etc. Usually all these worms feed on food (nutrients) we ingest and reproduce in our GI system. Our guts are lovely home for some worms especially for pinworms. However, there are some worms who live in other parts of our bodies such as blood, brain, eyes, liver etc.

Some worms can be transmitted from animals to human while the others (pinworms) can't.

Today, we are going to look into pinworms, that could be usually treated by OTC (over-the-counter) medicines.

What are pinworms? 

Image of pinworm/threadworm

Pinworm is very common in New Zealand. Pinworm is also commonly known as threadworm.  To date, it is believed that human is the only host that threadworm prefer (lucky us. lol). Almost everyone has the chance to be infected by threadworms.

Threadworms, as what its name tell us - is a cotton-like threads that is about 5-10 mm long.

Threadworms can be easily spread around. If you inhale the dust containing threadworm's eggs, they can then grow in your lower GI tract. It can be also spread by contact - saliva from others, personal things sharing , and infected surface (eggs can survive few days to weeks even they are outside the human body).

When threadworms or eggs are being swallowed, they will hatch in your gut and stay around your over gut, At nighttime, the female adult threadworms will travel to your bottom and lay thousands of eggs (sounds scary), which stick to your bottom with "glues". Those "glue" may cause allergy reactions and result in itchiness.

If you scratch your bottom and do not wash your hand properly, you may ingest the eggs and re-infect yourself [feacal-oral route transmission]. So, personal hygiene is crucial. Your mum is right ! Wash your hands before you eat.

What makes you think you or your kids have worms? 

Usually, we notice our kids have worms when they keep scratching their bottoms or complain about itchiness around their bottoms especially at night time.

There are other signs that you or your kids may have worms

- bedwetting or teeth grinding ( which they normally do not have)
-restlessness at night
- become irritable or tired during day time because of lacking sleep

Sometimes, the intense scratching can damage the skin around the bottom and cause secondary infection. If there is oozing , weepy or crusty


Rarely, they will complain about stomach discomfort or abdominal pain.

Usually, we do not have to diagnose worms by physically spotted worms around the bottom. The worms and their eggs are tiny that hardly spotted with bare eyes.

However, if you are concerned and want to see if they have worms, you can do this at night after your child sleeps. Use a torchlight to help you observe if there is presence of white thread-like moving creatures (threadworms). Or you can simply look at your child stools to see if there is presence of white threads.

Treatment options 

Anthelmintic (anti-worm) medicines can be used to get rid of the worms. 

For pinworms, the common two medicines used on the market is either mebendazole or pyrantel. 

(a) Mebendazole 

eg Combatrin-1

-mebendazole works by reduce the absorption of glucose by worms and eventually starve the worms to death. 

- can use to treat every single member from family ( unless pregnant or aged < 2 years) as single dose. 

- may repeat treatment after 2-weeks if required. 

Talk to a pharmacist if the child is under 2-years. Under certain conditions, pharmacist may recommend the use of this medicine for those who are > 6 months. 

The formulations available on the market is either chewable tablet or liquid form. If the kids still cannot swallow well, can crush the chewable tablet and mix them in food

Combatrin-1 - single dose treatment of threadworms

Single  dose treatment - mebendazole 100 mg 

Vermin containing mebendazole 

(b) Pyrantel 

- pyrantel works by paralyses ("stunt") the worms and thereby losing their ability to cling on to the bowel wall go our gut. As a result, the worms are flushed out from our body together with stool whilst we pass our motion.

-it is believe that pyrantel could be more effective than mebendazole, but you need to calculate the dosing or you can get help form pharmacy staff (believe me, it's easy calculation)

- For pyrantel, we need to calculate the dosing for each family member  (child aged > 2 years and adult) based on weight - 10mg/kg.

- (pyrantel is safe for those aged more than 12-months and onwards)

 e.g. If your kid is 20 kg, then give 2 squares (200mg) to him/her

Calculation: 20 kg x 10 mg/kg = 200 mg
           
1 square contain 100 mg , therefore 2 squares (200 mg) are needed

may repeat 2-4 weeks after treatment

Combatrin - contain pyrantel 

Combatrin contain pyrantel 

Advice 

Personal hygiene is imperative in preventing the spread or re-infection of threadworms.

Wash your hands frequently (especially before eating, after going to toilets)  [as we knows the worms could be transmitted via fecal-oral route]. 

Therefore, train your kids to have a good practice of cleanliness 

(i) use washing gel or sanitiser in school often. 

(ii) Keep fingernails short and clean 

(ii) Abstain from nail biting or finger sucking 

Wash bed linen (to get rid of threadworms and their eggs) using hot water 

Referral point 

 - If scratching caused oozing pus, crusty or angry read skin , refer to a pharmacist or doctor
- if customers have been to overseas ( especially developing countries or remote area) within past 24 months (some worms grow very slowly)
- unexplained decrease in weight
- pregnant ladies
-allergy to OTC medicines (mebendazole or pyrantel)
-have tried anti-worms medicine but do not seem to work

References 

1. https://medlineplus.gov/druginfo/meds/a608048.html

2. https://medlineplus.gov/druginfo/meds/a610019.html

3. https://medlineplus.gov/druginfo/meds/a682315.html

4. http://www.combantrin.co.nz/treatment.html

5. https://medlineplus.gov/druginfo/meds/a682820.html



NB: the pictures displayed were obtained form Google search images.

Head lice - Comb ! Comb! Comb !

Head lice

Head lice, or commonly known as “nits” are one of the common health condition  among children. Other names include  “kutu bugs” and “head louse”. Head lice is wingless parasites (I guess less scarier than cockcroach as they can’t fly), that feed on human’s blood on the head ( a few times daily – sounds scary).  

Worry not!

Most of the children may experience head lice issue at some point throughout their school life.  Bear in mind, head lice can affect anyone as long as they comes into close contact.

Usually, it could be quite frustrating for parents when their kids have head lice  as it may affect all the children at home and the children may be re-infected from time to time if the infected children in the child care or schools are not being treated.

One of the common misconceptions is that you are a dirty child if you get infected by head lice. This is not true! It’s not an issue of hygiene. Head lice cannot differentiate clean and dirty hair – they just want a home on your head.

Symptoms and signs

Usually , one of the signs of head lice is the itchy scalp – you can see the child keep scratching it or compaint of itchiness. 

Home detection for head lice can be done by using “wet-combing method”  - apply conditioner on the dry hair and comb the hair – you can detect the head lice (about 2-3 mm).

Or you can observe the eggs (also called as nits) – white colours spots on the shaft of the hair. 

[ to be exact, "nits" stands for the eggs of head lice, but usually people refer "nits" as head lice]. The eggs sometimes could be misunderstood as her dandruff. One thing about nits is they are not as flaky as dandruff and fall off once you scratch your head. The "nits" could only be pulled off by pinching it using your thumb and forefinger. 

How can we minimise the spead ?

Once your children got head lice, please tell the teacher or child carer so that the others kid can be checked if they have head lice too.

Treat head lice as soon as possible to reduce the spread.

For those with long hair, tie up the hair whne go to school or daily child care.

Unlike scabies treatment, you do not have to wash your clothing and bed sheets. 

Treatment options

The "ultimate power" to treat head lice is  THE COMB. COMBING the hair frequently with fine tooth nit comb can get rid of the head lice! 

Not only flying, head lice also cannot jump or swim. They hold on to the hair tightly with their claws. Hence, once you comb your hair and break their legs – they can no longer lay eggs (female one, of course) nor infect another people if they fall off the head. 

As mentioned before, head lice can’t fly, the only way for head lice  to spread around is  through close contact. Despite the fact that head lice cannot fly, they can quickly crawl across from one’s hair to another’s within seconds. 

Head lice 

You can easily get head lice treatment from a pharmacy.

There are different formulations available on the market – head lice shampoo, spray and lotion.

When you apply shampoo or lotion or any head lice products on the hair - make sure that you apply thoroughly , especially hair near the back of your ears.

Pictures below show some of the head lice products 

Electrical comb - comb through DRY hair 

Suitable for adults and children aged 6-months and over

Some products contain natural ingredients or herbs. Usually, they work by suffocating head lice. 

Contains tea tree or eucalyptus oil , organophosphates 

The eggs hatched in 7-10 days. Therefore, you can repeat the treatment after 7-days to get rid of any new head lice hatched from the eggs.


There are a lot of products available on the market. If you have any concern, always talk to a pharmacist or doctor for further information. 

References
 

1.     http://www.kidshealth.org.nz/head-lice

2.     http://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/head-lice

3.     http://www.cyh.com/HealthTopics/HealthTopicDetailsKids.aspx?p=335&np=285&id=1482

4.     http://www.bmj.com/company/products-services/#service15

5.     https://www.dermnetnz.org/topics/head-lice

6.     https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=head+lice&_ga=1.257621195.1117059492.1472983434

7.