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be no advantage in increasing this recommended frequency, reducing the frequency can be appropriate in the later stages of histological healing (pp. 67 and 80). Thus a therapeutic effect can then be expected using a topical steroid once on alternative days. The frequency of use on different parts, such as the scalp, should follow general principles adapted by particular practical considerations. The amount of topical steroid used on a part on one particular application should only be sufficient to 'shine the skin'. It is unnecessary and counterproductive to rub in the cream or ointment. 'Wiping on' is the optimal method. Use of the 'only a shine is necessary' principie will always ensure that only appropriate amounts are used. If the topical steroid is applied before the emollient, the 'shining technique' is easy to achieve. When deciding on the amount of topical steroid to prescribe on a particular occasion, apart from the patient's own practical experience, two over-riding and important principles must be borne in mind. Overgenerous prescribing, combined with a planned programme based on total healing as the aim, is preferable to under-prescribing, with attendant risks of inadequate treatment. Once the aim of treatment has been achieved, there seem to be no disadvantages in having a half-empty tube remaining. Secondly, should the patient come close to running out, they should know how to get a fresh supply, and understand the importance of doing so. The length of the active treatment programme The Combined Approach aims to establish topical treatment as an intermittent rather than continuous process. Taking account of the four weeks required for a normal basal cell to progress to shedded squame, it is not surprising that it may require four to six weeks topical treatment to achieve first cosmetic, then histological healing when treating chronic eczema. An acute relapse can however be successfully managed in as many days, using the same two-phase model. Premature cessation of treatment in either chronic eczema or acute relapse will be followed by further acute disease sooner rather than later. The effect of The Combined Approach is to reduce the total amount of topical steroid used, with consequent reduction in any likelihood of local or systemic sideeffects.

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Profile for Christopher Bridgett

Atopic Skin Disease - A Manual For Practitioners  

An account of a new behavioural approach to the treatment of atopic eczema, written for practitioners, but also for patients

Atopic Skin Disease - A Manual For Practitioners  

An account of a new behavioural approach to the treatment of atopic eczema, written for practitioners, but also for patients