Print & Bring this form to your clinician for an effective eczema management:

* Bathe _______ times a week. Wash only the area around the mouth, hands, feet, and genitals on the no-bathe day. Use a mild hypoallergic soap. Avoid a washcloth. The water should be tepid (hot water is irritating). Avoid bubble bath. Pat the skin dry with a towel and immediately apply a moisturizer after bathing.

* Shampoo the scalp ________ times a week. Use ____________________ . If the scalp is flaking, use _____________________ and leave it on the scalp for about 15 minutes. Rinse it thoroughly.

* Apply ________________________ a local or topical medication to control the inflammation. Use a thin film of ointment or cream on the area with the rash as directed by your clinician. Massage the ointment or cream well.

* Apply ________________________ a moisturizer after you use the anti-inflammatory topical medication. Use a thick or liberal amount of moisturizer to your child’s face and entire body.

* Give your child an antihistamine, ___________________________ , to reduce itching. Follow the instruction of your clinician on the frequency. Sometimes it might be needed all day. The dose of the antihistamine is _______________________ .

* If there is a sign of skin infection, __________________________ antibiotic should be given at a dose of ____________________________________ .

* If there is high fever, pain, or the rashes are getting worse in spite of the above medications, call your clinician.

Phone number of your clinician: _______________________

Phone number of your pharmacist: _____________________

Weight of your child: ________ pounds (your clinician will need this a prescription of oral antibiotic is needed)

Food and Medication allergy: ________________________

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