Diluted Steroid Facial Wet Wraps for Childhood Atopic Eczema

Recent epidemiological studies have suggested that atopic eczema (AE) is on the rise [1, 2]. Despite advances in the understanding of its immunopathogenesis, severe AE presents a management challenge to clinicians. In a small proportion of patients, the face can be the worst affected area and impose significant physical and psychological stress on schooling and daily activities. For children who have severe facial eczema and who are compliant, a short period of diluted steroid wet-wrap dressings on the face can often be helpful.The child is allowed to lie comfortably supine. Long scalp hair can be covered with a shower cap and the external auditory meati protected by cotton or plastic plugs to avoid inadvertent entry of water during treatment. The face is cleansed with warm water (about 25–30°C) and mopped dry. The dry parts of the forehead, central face, cheeks, chins, cutaneous lips and ear auricles are smeared with emollient, whereas a thin layer of a highly diluted steroid is applied onto the eczematous areas. The whole face and sometimes the upper neck, if also affected by eczema, are dressed with a double-layered wet gauze. The gauze sheets can be trimmed to fit individual regions and cuts made carefully to expose orifices (fig. 1). The next step is to apply a double-layered dry gauze on top of the wet gauzes. Adhesive tapes such as Micropore (3M Health Care, St. Paul, Minn., USA) can be used to secure various parts (fig. 2). This is further secured with Netelast (Seton Healthcare Group Plc, Oldham, UK), an elastic net bandage, and then with adhesive tapes at appropriate positions ending up as a facial mask (fig. 3). Size F of Netelast is most often used.In my experience, aqueous cream (formula: emulsifying wax 9%, white soft paraffin 15%, liquid paraffin 6%, phenoxyethanol 1%, add water to 100%) or emulsifying ointment (formula: white soft paraffin 50%, emulsifying wax 30%, liquid paraffin 20%) is used as emollient and diluent, and a new-generation topical corticosteroid such as 0.1% mometasone furoate (MF; 0.1% Elomet Ointment, Schering Canada Inc., Pointe Claire, Quebec, Canada) is used for treating the eczema. The preparation of a desired diluted topical steroid has been described elsewhere [3]. Briefly, aliquots of a steroid and a diluent are weighed using an electronic balance. Both components are dispensed in a single plastic medicinal box. Parents are instructed to mix them evenly when used and to use up the mixture within a short period of a few days to ensure stability of the mixture. Thus, a steroid to be diluted to 10% of its original concentration would mean one part of steroid added to nine parts of diluent. For base compatibility, a steroid cream is to be mixed with aqueous cream and a steroid ointment with emulsifying ointment. For wet-wrap dressings of the face, a 1-in-10 dilution of 0.1% MF cream or ointment is often used. However, depending on clinical situations, steroids of different dilutions can also be employed.The facial mask is usually kept for 2–3 h. Upon removal of the dressings, erythema and scaling would often have lessened. Open application of emollient can then be continued on a demand basis for the rest of the day. If in need, the procedure can be repeated once a day. In some patients where skin dryness dominates the clinical picture, plain emollient-only wet wraps can be used to reduce the skin dryness after their inflamed eczematous components have been controlled with diluted steroid wet wraps. Occasionally, patients may find the gauze sheets rough to the touch. In this case, a softer gauze with looser weaving such as Kerlix (A to Z Surgical Inc., San Jose, Calif., USA) could be used [4]. But Kerlix is not as easily available and cheap as the ordinary plain gauze sheets. Tubular dressings such as Tubifast (Seton Healthcare Group) can also be a comfortable and more convenient-to-apply alternative to plain gauze sheets but are more costly.Previous studies have shown that dilutes steroid wet wraps were beneficial for managing severe AE [3, 4, 5, 6, 7, 8, 9, 10]including a facial flare [4]. It is thought that the wet-wraps dressings enhance steroid penetrance, hydrate the stratum corneum and serve as a physical barrier against excessive scratching. However, occlusion also increases steroid absorption and the risk of local and systemic effects. Indeed, perioral dermatitis and adverse effects on the eyes [11]are unique to the prolonged application of potent steroid on facial areas. MF is a new-generation moderately potent to potent topical steroid having a high epidermal binding with minimal systemic absorption [12]. Hence the increased percutaneous steroid absorption consequent to occlusion and hydration can be reduced. In addition, MF has a very low risk of contact sensitization [13]. Facial wet wraps are useful for combating a flare of facial eczema. In the past year, 10 patients with flares of their facial eczema were given the treatment. They included 6 male and 4 female patients with a mean age of 8.4 years (range = 4–15 years) and long duration (mean = 7.15 years, range = 4–14 years) of childhood AE. All patients and their parents had preceding experience of using diluted steroid wet-wrap dressings for the four limbs and/or the body. For treating facial eczema, an intermittent regime of a 2- to 3-hour wrapping once a day for a few consecutive days was used. All parents reported good response and no significant clinical cutaneous signs of steroid side-effects were noted.However, to my current opinion, steroid wet wraps are most suitable for dry eczematous lesions. In cases of grossly exudative or infected eczema, wraps should best be withheld to avoid predisposing or exacerbating skin infections, and a short course of antibiotic and open application of steroid cream with or without topical antimicrobials is more desirable and preferred. Recently, Abeck et al. [9]have treated 6 patients with acute exacerbated atopic exzema using wet wraps with emollient-antiseptic preparations without steroids and achieved clinical improvement and reduction of Staphylococcus aureus colonisation. Such modification can therefore be more appropriate than using diluted steroid for weepy and excoriated eczema. The facial dressing procedure may scare some young children and babies. Therefore, before commencing treatment, careful explanation on the procedure should be given to parents and patients, and demonstration by a nurse could be very helpful to the parents who will carry out the treatment. All in all, with supervision and proper use on selected cases, diluted steroid facial wet wraps are as safe and effective as wet wraps used for elsewhere, and patients will find the procedure well tolerable.The author expresses sincere thanks to Miss Lisa Wong and her nurse colleagues for their participation in the demonstration of the wet-wrap technique, parental supervision and patient education.

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