Atopic eczema, otherwise known as atopic dermatitis, is a persistent inflammatory itchy skin condition. It often develops early in childhood and is a disease of exacerbations and remissions. These flares may occur as much as 2 or 3 a month. In severe cases the inflammation may be continuous.
History points to ask • Timing of onset and pattern of flares • Triggers of flares (eg soap, shampoo, pets, pollen, dust, specific food, synthetic clothing) • Previous treatment and response • Impact on day to day life • Atopy history, both personal and family • Growth and development • History of any reactions to foods • Any gastro intestinal upset
Diagnosis and Grading of Eczema It is important grade the severity of eczema so that treatment can be tailored appropriately.
Impact on quality of life and psychosocial wellbeing
Normal skin, no evidence of active atopic eczema
No impact on quality of life
Areas of dry skin, infrequent itching (with or without small areas of redness)
Little impact on everyday activities, sleep and psychosocial wellbeing
Areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening)
Moderate impact on everyday activities, psychosocial wellbeing and frequently disturbed sleep
Widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of skin pigmentation)
Severe limitation of everyday activities and psychosocial functioning, with nightly loss of sleep
A diagnosis of eczema can be made when there is itchy skin with 3 or more of the following: • Visible flexural dermatitis • Personal history of flexural dermatitis (or cheeks, extensor areas, or trunk if under 18 months) • Personal history of dry skin in last 12 months • Personal history of asthma or allergic rhinitis (or in first degree relative in under 4 yrs) • Onset under the age of 2 yrs
Please note that in Asian, black Caribbean or black African patients, look for skin darkening and extensor surfaces. Discoid or follicular patterns are more common in these ethnic groups.
Differentials • Think about food allergy in children with atopic eczema where skin reaction is immediately after food ingestion and also has issue with colic, vomiting, persistent loose stool and/or failure to thrive • If under 6 months and formula fed with moderate or severe eczema not responding to treatment, offer a 3-4 week trial of hypoallergenic (extensively hydrolysed or amino acid) formula and reintroduction of cow’s milk formula to see if there is improvement and deterioration (see Cow’s Milk Allergy information) AND refer to Allergy Clinic If under 6 months and breastfeeding with moderate or severe eczema not responding to treatment, it is not clear if altering mother’s diet is effective in reducing eczema. If food allergy strongly suspected, trial of allergen avoidance under dietetic supervision – see ‘Referrals’ AND refer to Allergy Clinic
‘Red flags’ for urgent/same day assessment
• Eczema herpeticum – if suspected needs to be seen same day by paediatric team. Look for areas of rapidly worsening, painful eczema with clusters of blisters, or punched out lesions, fever and/or lethargy.
• Severe bacterial infection – widespread infected eczema with pustules
These should be referred to Paediatrics by calling the PAU Telephone via switchboard.
The overall aim of eczema management is to minimise impact on quality of life, including school and attendance. The choice of emollients and steroid cream is guided by severity of eczema.
Mild atopic eczema
Moderate atopic eczema
Severe atopic eczema
Mild potency topical corticosteroids
Moderate potency topical corticosteroids
Potent topical corticosteroids
Topical calcineurin inhibitors
Topical calcineurin inhibitors
It is recommended that every patient has a written personalised management plan with step wise advice on emollient and steroid use. Practical demonstration of correct use of emollients and steroid creams advised, or direct to useful online resources if unable to do so (see below). Ensure to manage co-morbidities (asthma, rhinitis, food allergy), only use antihistamines in severe eczema or itching. Long term, ensure monitoring of growth, development, nutrition and diet. The child should have weight and height regularly plotted on an age appropriate centile chart, watching for evidence of faltering growth.
Advice to give to patients • Avoidance of irritants • Regular and correct administration of emollients when skin is clear • Advise to start treatment as soon as symptoms appear and continue for 48 hours after resolution • Signpost to patient support groups (see under ‘Supporting Information’)
Emollients • Unperfumed emollients to use every day and may be a combination of products, ie a cream and an ointment for more affected areas • Prescribe in large quantities (250-500g per week) • They can apply topical medications in any order, but try to leave 10 minutes between different products • For detailed advice on prescribing emollients, see the emollient factsheet on national eczema society website o Eczema.org – Emolients
Steroids • Tailor the potency of steroid to the severity of eczema, to be used once a day in under 12 years, preferably after bath in the evening • For the face use mild steroids, except for short term (3-5days) use of a moderate steroid in a severe flare • In vulnerable areas, such as axillae or groin, use moderate or potent steroids for a short course only (7-14 days) • For detailed advice on prescribing topical steroids and advice to give on education of amount of cream to use, see the topical steroid factsheet on the national eczema society website o Eczema.org – Topical Steroids
Topical calcineurin inhibitors, bandages, phototherapy and systemic therapy would usually be started in secondary care.
Infected eczema Is there are any weepy areas, pustules or crusting of the eczema, this is evidence of infected eczema. The most likely organisms are streptococcus or staphylococcus. Check local guidelines on antibiotics, but flucloxacillin is usually first line treatment for both staphylococcus and streptococcus, or erythromycin in penicillin allergy. Topical antibiotics should be reserved for cases of clinical infection in localised areas and used for no longer than 2 weeks. Ensure to let families know to obtain new supplies of topical mediations after treatment to avoid contamination.
If any evidence of systemic infection will need same day referral to paediatrics.
Steroids • Tailor the potency of steroid to the severity of eczema, to be used once a day in under 12 years, preferably after bath in the evening • For the face use mild steroids, except for short term (3-5days) use of a moderate steroid in a severe flare • In vulnerable areas, such as axillae or groin, use moderate or potent steroids for a short course only (7-14 days) • For detailed advice on prescribing topical steroids and advice to give on education of amount of cream to use, see the topical steroid factsheet on the national eczema society website o https://eczema.org/wp-content/uploads/Topical-steroids-Sep-19.pdf Topical calcineurin inhibitors, bandages, phototherapy and systemic therapy would usually be started in secondary care.
Advice to give to patients
• Avoidance of irritants • Regular and correct administration of emollients when skin is clear • Advise to start treatment as soon as symptoms appear and continue for 48 hours after resolution • Signpost to patient support groups (see under ‘Supporting Information’)
Please refer the following children: • Children with atopic eczema who have suspected cow’s milk allergy after a short trial of cow’s milk exclusion ( maximum 4 weeks) should be referred for specialist dietary advice (Paediatric Dietitian via ERS) • Moderate to severe eczema in an infant under 6 months of age (Paediatric Allergy Clinic via ERS) • Early onset eczema ( <2 years of age) with suspected food allergy i.e. temporal relation to specific foods (Paediatric Allergy Clinic via ERS)
Please refer the following children to Dermatology or General Paediatrics via ERS:
Cases can be discussed via Advice & Guidance on ERSor the Paediatric Advice Telephone if you are unsure or would like to discuss further.
• Diagnosis is uncertain • Facial eczema that has not responded to treatment • For specialist advice on treatment (ie wet wrapping, topical calcineurin inhibitors) • Patient or family may benefit from specialist advice on treatment • Contact allergic dermatitis is suspected • It is causing significant or psychological problems • Recurrent severe infections, deep abscesses or pneumonia • Faltering growth • Management has not controlled the eczema based on assessment by the child or parent
The following children will need same day (acute referral) to PAU using the PAU telephone: • Eczema herpeticum – if suspected, needs to be seen same day by paediatric team. Look for areas of rapidly worsening, painful eczema with clusters of blisters or punched out lesions, fever and/or lethargy. • Severe bacterial infection – widespread infected eczema with pustules
Atopic eczema in under 12s: diagnosis and management (2007) NICE Guideline cg57
Allergy care pathway for children with eczema (2011) Royal College of Paediatrics and Child Health
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