Atopic dermatitis — the most common form of eczema — affects roughly one in five children and one in ten adults in the United Kingdom, according to the National Eczema Society. Community pharmacists are frequently the first healthcare professional patients consult, making the pharmacy counter a critical intervention point for this chronic, relapsing condition.

What pharmacists see at the counter

Patients typically present with dry, itchy, inflamed skin. In children, the face, scalp and extensor surfaces are most commonly affected; in adults, flexural areas such as the antecubital and popliteal fossae predominate. The itch–scratch cycle drives much of the morbidity: sleep disruption, secondary infection and psychological distress.

Pharmacists should ask about duration, distribution, family history of atopy (asthma, hay fever, eczema) and any identified triggers. A presentation lasting less than two weeks with no atopic history may suggest contact dermatitis or another cause — and warrants different advice.

The emollient foundation

NICE Clinical Guideline 57 is unambiguous: emollients are the mainstay of eczema management at every stage of severity. They should be applied liberally and frequently — at least twice daily and ideally three to four times — even when the skin appears clear.

Choosing an emollient

The right emollient is the one the patient will actually use. Ointments are more effective at trapping moisture but feel greasy; creams are more cosmetically acceptable. Pharmacists should offer samples where possible and explain that patients may need to try several before finding one they will use consistently.

Key counselling points:

• Apply emollients in the direction of hair growth to reduce folliculitis risk
• Use a clean spoon or spatula to scoop from tubs — fingers introduce bacteria
• Wait at least 30 minutes between applying emollient and topical corticosteroid
• Emollients containing sodium lauryl sulfate (SLS) may irritate eczematous skin and should be avoided as leave-on products, per MHRA advice (2013)

Soap substitutes are equally important. Standard soap, shower gel and bubble bath strip skin oils and worsen the barrier defect. Recommend emollient wash products such as Dermol 500 lotion, Cetraben bath additive or aqueous cream used as a wash (not as a leave-on moisturiser).

The topical corticosteroid ladder

When emollients alone do not control flares, topical corticosteroids remain the first-line anti-inflammatory treatment. The ladder runs from mild to very potent:

Pharmacists can supply hydrocortisone 1% over the counter for mild flares in adults and children over 10 (face excluded). For anything requiring moderate potency or above, patients should be directed to their GP.

Counselling on corticosteroid use:

• Apply a thin layer to affected areas only — the fingertip unit (FTU) system helps patients gauge the correct amount
• Use for the prescribed duration (typically 7–14 days for a flare), then step down
• Morning application may be more practical, though timing matters less than consistency
• Steroid phobia is common — reassure patients that short courses of appropriate-potency steroids are safe and that under-treatment leads to worse outcomes than measured use

Identifying and managing triggers

Common triggers include house dust mite, pet dander, certain fabrics (especially wool), temperature extremes, stress and food allergens in young children. Pharmacists can provide practical advice:

• Cotton clothing next to the skin; avoid wool and synthetic fibres where possible
• Keep bedroom temperature cool (16–18°C) and humidity moderate
• Use non-biological washing detergent and avoid fabric conditioner
• Cut fingernails short to reduce scratch damage — cotton mittens at night for young children

Food allergy testing should only be recommended via a GP or allergy clinic referral. Pharmacists should avoid suggesting elimination diets without clinical guidance, as these can lead to nutritional deficiency, particularly in children.

Recognising secondary infection

Eczematous skin is vulnerable to bacterial and viral superinfection. Signs that should prompt urgent GP or same-day referral include:

• Weeping, crusted, yellow or golden patches — suggesting Staphylococcus aureus infection
• Rapidly spreading painful vesicles — potentially eczema herpeticum, a dermatological emergency requiring same-day assessment
• Fever or systemic unwellness alongside a flare

Pharmacists should be alert to eczema herpeticum in particular. It presents as clustered, monomorphic, punched-out vesicles, often on the face, and can progress rapidly. This is a referral-now presentation.

When to refer

Beyond secondary infection, pharmacists should refer patients to a GP when:

• Emollients and OTC hydrocortisone are not controlling symptoms after 7–14 days
• Eczema is affecting sleep, school attendance or quality of life
• The face, eyelids or genitals are significantly affected
• There is suspected allergic contact dermatitis (occupational exposure, new products)
• The patient is under 2 years old with a first presentation

For severe or treatment-resistant eczema, GPs may refer onward to dermatology for phototherapy, immunosuppressants (such as methotrexate, ciclosporin or azathioprine) or the newer biologic dupilumab (Dupixent), which has transformed outcomes for moderate-to-severe atopic dermatitis since its NHS approval.

The pharmacy role in long-term management

Eczema is a chronic condition requiring ongoing support. Pharmacists are well placed to:

• Review emollient use at each purchase — patients often under-apply or stop during remission
• Reinforce the importance of maintenance therapy between flares
• Monitor for signs of topical steroid overuse or underuse
• Support parents managing childhood eczema, who may face conflicting advice online
• Signpost to the National Eczema Society for peer support and evidence-based resources

With more than 13,000 community pharmacies in England, according to NHSBSA contractor records, pharmacists provide the most accessible healthcare touchpoint for the estimated 6 million people living with eczema in the UK. Effective counter management reduces GP appointments, prevents complications and — most importantly — improves patients' daily lives.

For pharmacists looking to develop their dermatology knowledge further, the PharmSee salary guide tracks roles in specialist dermatology pharmacy, while the job search tool lists current vacancies across community and hospital settings.

Sources: NICE CG57 Atopic eczema in under 12s (updated 2023); NICE CG153 Eczema in over 12s (2007, reviewed 2021); MHRA Drug Safety Update on aqueous cream SLS content (2013); National Eczema Society prevalence data (2024); NHSBSA dispensing contractor records.