Treatment in specific localisations
Scalp/Capillitium: Normally solutions and liquids are used but oils and ointments may also be utilised. Involvement of the scalp may especially occur in moderate and severe forms of AD and seborrhoeic dermatitis. Mild shampoos or ketoconazole shampoos are used to remove scales and crusts. Tar shampoos can help, especially with the pruritus, if the dermatitis is not too acute. Specific topicals containing corticosteroids or other agents are chosen depending on the underlying type of eczema and the individual skin condition.
Face: Caution is required when treating this region because the face bears a special risk for the development of cutaneous atrophy. Less potent topical corticosteroids such as hydrocortisone or desonide are appropriate for the face. More potent ones such as methylprednisolone aceponate or mometasone furoat should be used if other topical therapies fail and professional (dermatological) surveillance is available. Topical immunomodulators can be applied on the facial skin and have shown good results in treating eczema of the eyelids and the perioral region.
Hands and feet: The palms and soles have the thickest skin of the whole body leading to lesser penetration and absorption of active substances in topicals. From the clinical point of view, this leads to slower amelioration of the skin disease. Topical immunomodulators have been shown to be less effective compared to other body regions. This may be due to impaired penetration of the active substance. Tar preparations, corticosteroids and emollients represent topical treatment options in most forms of eczema. More potent corticosteroid ointments may be required for palms and soles. In dyshidrotic eczema, tanning agents applied as bath, solution, lotion, gel or cream are effective in drying out the vesicles.
Lower extremities: Chronic venous insufficiency of the lower extremities may come along with stasis dermatitis. The major aim of treatment includes the management of venous hypertension by symptomatic measures such as compression bandages or stockings and, if indicated, surgical therapy (removal of insufficient saphenous veins, ligation of incompetent communicating veins). As dry skin is a common finding in stasis dermatitis, regular hydration of the skin is necessary. In severe cases, topical therapy with corticosteroids may be necessary. These patients are prone to develop sensitisation against one or more ingredients of topicals leading to contact allergy. In such cases, allergy testing is mandatory in order to identify the relevant contact allergens. This enables the selection of the appropriate topical medication. Patients suffering from ulcers may develop wound exsudates leading to irritant contact dermatitis. In these cases, creams or lotions with antiseptic properties may be more appropriate because the surrounding skin is frequently inflamed and macerated.
Intertrigineous areas: This term stands for the groins, the axillae and the inframammary folds. In the axillae, cutaneous absorption is more than three times greater compared to the forearm and about ten times greater compared to the plantar surface. Occlusion, either occuring naturally in a cutaneous fold or induced artifically by dressings (e.g. hydrocolloids), can enhance cutaneous absorption up to ten times. The skin area under diapers is also considered an “intertrigineous region”, not only because it includes the groins, but also because the penetration and absorption of active substances is higher under occlusion.The intertrigineous areas are more prone to develop corticosteroid-induced cutaneous atrophy. Therefore, caution is required in these areas and less potent topical corticosteroids such as hydrocortisone or desonide are appropriate.
Anal/Genital: The cutaneous absorption is about 40 times greater at genital regions such as the scrotum compared to the forearm. In these areas, topical treatment modalities have to be carefully chosen in recognition of the increased skin permeability. Less potent topical corticosteroids such as hydrocortisone or desonide are to be favoured and should be restricted to a reasonable period of time.