01Purpose and principlesWhat the treatment does and how it fits into care.
An emollient prescription is a formulation and behaviour decision. Ointments contain little water and suit very dry non-hairy skin; creams are less greasy; lotions spread over hair but are less occlusive. Stinging can reflect cracked skin or an irritant ingredient rather than allergy. Offer alternatives and enough quantity rather than abandoning barrier care.
Topical corticosteroid safety depends on potency, quantity, site, duration and occlusion. Teach the name and potency, mark a body map and demonstrate fingertip units. Separate emollient and steroid application by enough time to avoid dilution or spreading the steroid to unaffected skin; BAD advises either may be applied first with about twenty minutes between.
Emollients, topical corticosteroids and fingertip units care should combine visible inflammation with itch, pain, sleep, occupation and treatment burden. Agree where each product goes, how much is used and when response will be reviewed; explain urgent features separately so normal fluctuation is not confused with infection or treatment failure.
Key points
- Choose an emollient the patient will use: lotion spreads easily on hairy or weeping sites, cream is acceptable by day, and ointment reduces water loss most but is greasy and occlusive.
- Use emollient frequently and liberally, including as a soap substitute; pumps or clean spoons reduce contamination compared with repeated fingers in a tub.
- All emollients can contaminate clothing, bedding and dressings and increase fire severity; keep away from flames, cigarettes and ignition sources even after fabric feels dry.
- Match corticosteroid potency to diagnosis, age, site and thickness: mild for many thin sites, stronger for thick palms or soles, and very potent only for selected short supervised use.
- One adult fingertip unit is the cream or ointment from fingertip to distal crease of an adult index finger and covers about two adult handprints of skin.
- Apply topical corticosteroid to active inflammation, not as moisturiser; a once-daily preparation should not be doubled without a product-specific reason.
- For Emollients, topical corticosteroids and fingertip units, document body sites, severity, sleep and function, recent treatment, infection features and what the patient can realistically apply each day.
- In Emollients, topical corticosteroids and fingertip units, reassess the diagnosis when a well-used, correctly potent regimen fails rather than repeatedly intensifying treatment without examining adherence, exposure and mimics.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Rough tight scale without warmth, swelling or itch flare needs emollient rather than corticosteroid escalation.
New itch, warmth, elevation, scale, vesiculation or colour change relative to baseline identifies sites for anti-inflammatory treatment.
Increasing pain, pustules, rapidly worsening crust, spreading erythema or systemic illness changes the plan and may require urgent assessment.
Atrophy, striae, telangiectasia, easy bruising, perioral change or rebound at a treated site suggests excessive exposure or wrong diagnosis.
Smoking, candles, gas fires, oxygen equipment or heavily contaminated bedding creates high-consequence ignition risk requiring explicit harm reduction.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Product and site reconciliationFirst step - Why
- Establish every leave-on, wash and corticosteroid formulation used on each anatomical area.
- Interpretation and limitations
- Brand and colour descriptions are unreliable; inspect containers, potency, expiry, ingredients and weekly quantity.
- 02
Fingertip-unit calculation - Why
- Convert treatment surface into a practical amount per application.
- Interpretation and limitations
- One adult fingertip unit covers about two adult handprints; age-specific paediatric charts and body size modify total quantity.
- 03
Skin examination for infection and adverse effects - Why
- Distinguish active eczema, residual pigment, infection and steroid harm before repeat prescribing.
- Interpretation and limitations
- A photograph may help comparison but cannot replace palpation for warmth, atrophy and tenderness.
- 04
Adherence and technique demonstration - Why
- Identify under-quantity, dilution, wrong sequence and fear-driven avoidance.
- Interpretation and limitations
- Ask the patient to show application and calculate how long a tube lasted rather than relying on a yes-or-no adherence question.
- 05
Medicine-specific baseline assessment - Why
- Check age, pregnancy, site, infection, immune status and interacting treatments before potent or extensive use.
- Interpretation and limitations
- The need for endocrine or ophthalmic assessment follows cumulative exposure and symptoms, not routine testing after every short course.
04Treatment approachPreparation, options, escalation and aftercare.
01Choose emollientMatch formulation and riskFirst stepDry or eczematous skin needs a tolerated leave-on product and soap substitute.+
- 1Offer a texture suited to dryness, hair, season and preference, avoiding aqueous cream as a leave-on choice when its surfactant irritates.
- 2Demonstrate smoothing with hair direction, frequent reapplication and hygienic pump or spoon dispensing, especially when infection recurs.
- 3Give fire-safety advice for every emollient and review stinging, folliculitis, contact allergy and whether prescribed quantity matches body area.
02Choose corticosteroidMap potency, quantity and durationActive inflammatory dermatosis is diagnosed and untreated infection or important mimic has been considered.+
- 1Select the lowest potency likely to control the specific site and thickness, following disease and product guidance rather than one potency everywhere.
- 2Write frequency, duration, stop or step-down point and fingertip-unit quantity on a body map and apply only to active skin.
- 3Review response and adverse effects before repeating potent or very-potent courses; failure should reopen diagnosis, contact exposure and technique.
03Use both safelyPrevent dilution and cumulative harmA patient needs daily emollient plus topical corticosteroid during a flare.+
- 1Continue emollient across dry skin and use the corticosteroid only on inflamed areas, separating applications by around twenty minutes.
- 2Wash hands after treatment unless hands are the target and prevent accidental transfer to eyes, children or another person.
- 3Record product totals and teach the patient to seek review for pain, pustules, blistering, spread or a flare that does not respond as expected.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Hydrocortisone 1% cream
Adults apply a thin layer once or twice daily to selected affected skin for no longer than seven days under this product licence.Avoid eyes, untreated infection and prolonged unsupervised face or flexure use; formulation excipients can irritate or sensitise and persistent symptoms need review.
Betamethasone valerate 0.1% cream
Apply thinly once or twice daily to selected affected skin for up to four weeks, then reduce frequency or potency as control is achieved.Avoid face, folds, genitals, untreated infection, large areas and occlusion unless directed; monitor atrophy, adrenal suppression risk and rebound.
Clobetasol propionate 0.05% ointment
Adults apply thinly once or twice daily to resistant thick plaques for a short specialist-directed course, not exceeding four weeks or 50 g in one week.Do not use on face or untreated infection; minimise area and occlusion, monitor systemic and local toxicity, and reassess when response is incomplete.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- At refill, compare expected fingertip-unit quantity with actual use and identify under-treatment, over-treatment or stockpiling.
- Review the body map after every potent course and inspect thin sites for atrophy, striae, telangiectasia and perioral change.
- Repeat fire-safety counselling when formulation changes, oxygen is introduced or a smoker joins the household.
- At review of Emollients, topical corticosteroids and fingertip units, compare itch, sleep, fissuring or ooze, affected sites, function and treatment use with the agreed baseline.
- For Emollients, topical corticosteroids and fingertip units, record adverse effects, new contact exposures and the safety-net for pain, fever, rapidly spreading disease, eye symptoms or systemic illness.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
A fingertip unit is an area tool
It converts a vague thin layer into enough medicine for roughly two adult handprints, reducing both fear-driven underuse and excess.
Potency is not percentage
Different corticosteroids cannot be compared by numerical concentration alone; the molecule, formulation and vasoconstrictor potency determine class.
Ointment increases delivery
Occlusive greasy vehicles often deliver steroid more strongly than cream and suit dry thick skin, while weeping or hairy sites may need another form.
Clean tubs prevent inoculation
Repeated fingers can contaminate an emollient pot; pumps or a clean spoon matter in recurrent infected eczema.
Fabric remains combustible
Washing may reduce but does not eliminate emollient contamination, so avoidance of flame and smoking remains necessary.
08Common pitfallsFrequent interpretation and management errors.
- 01
Prescribing apply thinly without stating site, potency, frequency, duration or fingertip-unit quantity.
- 02
Using topical corticosteroid as a whole-body moisturiser on non-inflamed dry skin.
- 03
Calling all steroid creams one percent and assuming the percentage determines potency.
- 04
Warning only users of paraffin-labelled products about fire when paraffin-free emollients can also increase fabric flammability.
- 05
Assuming a patient is non-adherent without asking them to demonstrate technique and show how long the container lasted.