Wet dressings are widely used at home, especially in the UK. Sometimes they are used without topical steroids but with simple emollients applied directly to the skin.
Whichever method is used, the effect of wet dressings can be very dramatic; it can make the child feel more comfortable with a reduction in itching and an improved sleep pattern. Wet dressings are undoubtedly a valuable tool for the treatment of children with severe generalized eczema; however, use at home requires good compliance and must be carefully monitored. It has been recommended by the National Patient Safety Agency (NPSA) that information is given to families about the potential fire hazard associated with paraffin-based skin products on clothing and dressings near an open flame (NPSA 2007, Rapid Response Report 4, 26th Nov 2007).
Paste Bandages
The use of paste bandages is of particular value for the treatment of intensely itchy and lichenified eczema on the arms or legs where scratching is causing excessive skin damage. They are ideal for localized areas, such as the wrists or lower legs/ankles. At GOSH we have traditionally used zinc oxide-impregnated bandages covered with Coban®, which is a dry, elasticated self-adhesive strapping. This can be left on for up to 5 days. Coban® is not advisable if there is a known latex allergy .The method of application is detailed in Table 192.5.
Table 192.5 The application of Ichthopaste and Coban® bandages (Fig. 192.2a–d)
| Action | Rationale |
| Preparation | |
| Explain the procedure to patient and caregiver including why it is indicated; use photographs and a doll if appropriate | To alleviate anxiety, determine the level of cooperation and ensure that informed consent to treatment is given |
| Ensure the topical treatments are prescribed on the patient’s prescription chart | To adhere to the medication policy |
| Assemble and prepare the following: Ichthopaste roll, Coban® bandage, emollient/topical treatment to be applied to the skin, round-ended scissors | |
| Select appropriate distraction toys for the child as he/she will be required to sit still during the treatment | To avoid boredom and anxiety during treatment |
| Administration | |
| Apply the emollient/topical therapy to the affected area | To reduce inflammation and maximize comfort |
| Legs and feet | |
| Wind the Ichthopaste bandage around the foot, overlapping one-half of the width of the bandage; bandage the ankle separately in the same fashion; work up the leg, occasionally reversing the direction of winding in order to make a pleat | This allows for shrinkage and maximum mobility; pleating and overlapping prevents a tourniquet effect from occurring |
| Arms and hands | |
| Using approximately 15-cm lengths, cover the palms and backs of hands; fingers can be bandaged separately as required; work up the arms, winding the Ichthopaste bandage around the arm, occasionally reversing the direction in order to make a pleat | As with the legs and feet |
| Coban® bandage | |
| Wind the Coban® bandage around the limb, leaving a small section of Ichthopaste showing at both ends | To secure the underlying Ichthopaste bandage and protect clothing |
| Release most of the tension from the bandage during use | |
| General measures | |
| Usually left in situ for 12–48 h, but can be left for longer | To prevent constriction |
| For home use: ensure that the caregiver is competent in application following demonstration | To ensure correct application |
| Support with written instructions; advise that treatment may stain clothing/bedding | To support verbal instructions |
Psoriasis
Dithranol Preparations
Dithranol is a time-honoured treatment for plaque psoriasis (Chapter 82). Traditionally, it has been used as an inpatient treatment incorporated at varying strengths (usually 0.05–2%) in Lassar’s paste (zinc and salicylic acid paste BP). It is left on for a defined period of time, dependent on the thickness of the psoriasis, the individual skin sensitivity and age of the child, usually from 30 min to 2 h. It must be explained to the family that dithranol produces a temporary brownish-purple staining of the skin and may ‘burn’ the normal surrounding skin if this is not protected.
‘Short-contact’ therapy can be undertaken by the patient as a day-attender at hospital. For children therapy should be supervised in a hospital unit by nurses who are experienced in applying dithranol preparations. In certain situations when parents are taught the treatment regimen it can be carried out at home with caution. Other formulations available include Dithrocream® 0.1–2%. The nursing procedure is detailed in Table 192.6.
Table 192.6 The application of dithranol preparations
| Action | Rationale |
| Preparation | |
| Explain the procedure to patient and caregiver, including why it is indicated; use photographs if appropriate | To alleviate anxiety, determine the level of cooperation and ensure informed consent to treatment |
| Ensure that the treatments are prescribed on the patient’s prescription chart and check each preparation | To adhere to the medication policy and ensure correct strength is used |
| Assemble and prepare the following: disposable gloves (for the nurse), dithranol preparation, white soft paraffin, talcum powder, arachis oil*, bath emollient, moisturizer, orange sticks and spatula, gauze squares, old pyjamas/gown or Tubegauze suit | |
| Select appropriate distraction toys for the child as he/she will be required to sit still during the treatment | Can be a lengthy treatment; need to prevent boredom and anxiety |
| Administration | |
| Apply white soft paraffin to all areas of healthy skin surrounding the psoriasis plaques | To prevent the dithranol burning healthy skin |
| Use either an orange stick or spatula (depending on size of plaque) to apply the dithranol preparation to the areas of psoriasis | To ensure the dithranol is applied carefully and accurately |
| Check the time of application | To ensure the dithranol is left on for the correct amount of time |
| Dust treated skin with talcum powder | To help keep the dithranol preparation in situ and prevent smearing |
| Dress the patient in old pyjamas/gown or Tubegauze suit | Dithranol will stain all contacts |
| Removal | |
| After the allocated time, remove the dithranol using gauze squares and arachis oil (or olive oil in cases of peanut allergy) | |
| Follow with a bath using an oily bath emollient | |
| Use a soap substitute to cleanse the skin, such as aqueous cream or emulsifying ointment |
* Olive oil can be used in cases of nut allergy.
Scalp Treatment
A traditional treatment for scalp psoriasis is the use of Cocois® (coal tar solution 12%, salicylic acid 2%, precipitated sulphur 4%, in a coconut oil emollient base). This is massaged into the scalp, left on for a defined period of time and then washed off with a prescribed shampoo, usually one containing coal tar (Table 192.7).
Table 192.7 The application of scalp preparations for psoriasis
| Action | Rationale |
| Preparation | |
| Assess the patient’s scalp psoriasis and record extent and severity | To monitor effectiveness of therapy |
| Explain the procedure to the child and caregiver, including why it is indicated; use photographs if appropriate | To alleviate anxiety, determine the level of cooperation and ensure informed consent to treatment is given |
| Ensure the treatments are prescribed on the patient’s prescription chart and check against the preparations | To adhere to the medications policy and ensure that the correct treatments are administered |
| Assemble and prepare the following equipment: disposable gloves, plastic comb, scalp ointment, shampoo | |
| Select appropriate distraction tools for the child, as he/she will be required to sit still during the treatment | To prevent boredom and anxiety |
| Administration | |
| The scalp ointment should be applied in a methodical manner by parting the hair in sections; part the hair with a comb and apply a smear of the ointment along the parting; use the comb to gently encourage any scale to lift from the scalp; reapply the ointment to the thickened encrusted areas; part the hair, 1 cm from the treated area and repeat until the whole scalp is treated | This technique ensures adequate coverage of the whole scalp |
| Leave in situ for the required time; a shower cap/scarf may be used | The longer it is left on, the more effective it is, ideally overnight |
| If left overnight, pillow cases should be covered | The treatment may stain pillow cases |
| After the allocated time, wash the hair with the prescribed shampoo | To remove the loosened scale/crust |
| Comb the hair against its natural fall | To gently lift any remaining scale, being careful not to pull out any scalp hairs |
| Additional points | |
| Carers should be involved in the treatment | In order to continue the treatment at home as necessary |
| Review the scalp with each treatment | To monitor effectiveness |
As the scalp improves, the duration of treatment and frequency can be reduced. At home it may be more practical to apply the scalp ointment at teatime, when the child returns home from school, leave it on for 2–4 h and wash off prior to going to bed.
Infections and Infestations
Care of the Dermatology Inpatient with MRSA
The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in the hospital setting as well as the community remains a concern. This is part of a much wider problem of antibiotic resistance. The carriage of MRSA is particularly relevant to children with chronic skin disease. In the community, skin colonization is not as much of an issue as it is in a hospital environment, where it can be transmitted to other patients, some of whom would be at risk because of immunosuppression. Often these strains are resistant to most common antibiotics, which can include fucidic acid (Fucidin®) and mupirocin (Bactroban®). The treatment of MRSA infection is usually with intravenous antibiotics, such as teicoplanin and vancomycin. Newer drugs now available include linezolid, daptomycin and tigecycline. There are strict infection control measures to prevent cross-infection within the hospital setting (Table 192.8).
Table 192.8 Care of the dermatology inpatient with methicillin-resistant Streptococcus aureus (MRSA) infection
| Action | Rationale |
| Environment | |
| Nurse in an isolation cubicle with an infection precautions sign clearly visible | To prevent transmission of MRSA to others and to alert those entering the cubicle |
| Keep the door closed at all times | MRSA can be airborne |
| Remove excess equipment from the cubicle before the patient is isolated | To prevent unnecessary items being contaminated |
| When bathing is required, if possible limit use of bathroom to MRSA patient only or clean thoroughly following each use | To prevent cross-infection |
| Ensure the bath is rinsed thoroughly after cleaning | To prevent skin irritation to next patient |
| The isolation room should be cleaned regularly during use and surfaces should be kept clean and dry | Reduces the risk of contamination |
| Staff/visitors | |
| Ensure MRSA status is recorded confidentially in all of the patient’s relevant medical and nursing documentation | Essential information |
| Limit the number of staff/visitors entering the cubicle at the same time | Reduces the risk of cross-infection |
| Prior to entry into isolation cubicle: wear plastic apron; wash hands; wear disposable gloves; collect all equipment required | To protect clothing and to prevent cross-infection |
| Prior to exiting isolation cubicle: remove plastic apron and gloves; wash hands | |
| Involve play specialist for activities | Child will be bored in cubicle; no access to playroom |
| Skin care | |
| In cases of colonization only, normal skin care regime should continue | |
| When attending to wound/skin care, hands should be washed before and after; and gloves should be worn | |
| Equipment | |
| Where possible, allocate equipment for sole patient use | Reduces the risk of cross-infection |
| Equipment should be kept clean and dry | Less likely to become contaminated |
| Do not take into the cubicle unnecessary equipment, including pens, notes and personal stethoscopes | To avoid unnecessary contamination |
| Clean/disinfect all equipment before removing from the room | To prevent cross-infection |
| General measures | |
| Give practical and reassuring support to the family | Acknowledging the stigma of MRSA status, and parental concerns |
| After discharge from hospital | |
| Thorough cleaning of the cubicle according to a strict hospital protocol |
Staphylococcal Scalded Skin Syndrome
Certain strains of S. aureus produce toxins, which can cause widespread skin peeling (Chapter 54). The source of infection is often the nasopharynx, umbilicus, skin wound, blood or as a result of breastfeeding. The symptoms develop within a few hours to a few days. The upper part of the epidermis peels off like wet tissue paper. Affected children can be very unwell and require high-dependency nursing care (Table 192.9). Treatment includes intravenous fluids, antibiotics and adequate analgesia.
Table 192.9 Nursing care of staphylococcal scalded skin syndrome
| Action | Rationale |
| On admission | |
| Nose, throat and skin swabs for culture and antibiotic sensitivities, including a specific request for an MRSA screen | For early detection of infection |
| Baseline temperature, pulse, respiratory rate and blood pressure, increase frequency as indicated | To obtain the normal range and detect deterioration of condition |
