SummaryTopical application of clobetasol propionate in a strength of 0 05% in cream or ointment (Dermovate) suppressed the hypothalamic-pituitary-adrenal axis in both normal people and patients with diseased skin. In normal people the 9 am serum cortisol level was suppressed when between 45 and 90 g was applied weekly. Insulin stress test results in patients with diseased skin showed an abnormally small response after long-term application of similar amounts. We conclude that long-term administration should be restricted to less than 50 g a week.Three volunteers applied 90 g clobetasol propionate cream weekly to their limbs (fig 1). In two the serum cortisol was completely suppressed by the eighth day; they then extended application of this amount to the whole body for a further week and suppression persisted. The third volunteer failed to show suppression and had a normal serum cortisol level throughout. In his case the experiment was repeated with identical results. Two further volunteers applied the cream to the whole body from the outset and also showed profound adrenal suppression. Fig 2 shows serial cortisol levels for one of these. The levels of the other rose, despite continued application, when he underwent an episode of stress associated with the delivery of his wife's first child.nmol/l 5001

The recent Dermatological Care Working Group report highlighted important deficiencies in the dermatology service in the UK and recommended that care should move closer to the patient. The report stated that 'expert patients' could become 'sharers in their care' and are best placed to improve their own self management. One area that could benefit greatly from increased patient education and participation is the use of emollients. Emollients are frequently prescribed for patients with eczema and other dry skin conditions. Although the benefits of emollient therapy are widely accepted, prescribing practices vary considerably, often according to physicians' individual preferences. Patients can receive confusing or conflicting treatment advice, leading to frustration, non-compliance, and difficulty in following an effective regimen. To promote the effective use of emollients it is important for patients and health professionals to understand the functions of the skin and the principles of emollient use and application. We propose a set of simple guidelines for emollient therapy in eczema care to improve day-to-day management by health professionals in the community and to promote consistent practices by patients. These guidelines form the ABC dry skin and eczema management programme supported by the National Eczema Society and accredited by the British Skin Foundation.

Widespread application of clobetasol propionate resulted in suppression of the hypothalamic pituitary axis in four patients. Three patients showed Cushingoid features and developed symptoms of adrenocortical insufficiency on withdrawal of clobetasol.

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Despite having genitourinary symptoms less than half the patients had been tested for infection prior to attending the clinic. More than a third of the patients, 46 (34%), were diagnosed with a genitourinary infection. There is a significant role for genitourinary services in the diagnosis, management and ongoing care of patients in a vulva clinic.