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Page last updated:
9 April 2024
The information below is based on NICE Clinical Guideline CG57 Atopic eczema in under 12s: diagnosis and management (December 2007 [last updated June 2023]).
Treatment of eczema depends upon individual circumstances. Examination and assessment of clinical features and the impact of any type of eczema on physical, psychological, and social wellbeing, will help with appropriate treatment therapies.
Emollients are essential in the management of eczema, and their regular use can alleviate symptoms and reduce flare-ups. See section 13.2.1 Emollients.
Emollients containing active ingredients are not generally recommended because they increase the risk of skin reactions, however they may be useful in some people.
Calcineurin inhibitors (e.g. topical tacrolimus or pimecrolimus) may be useful as second line / alternative options for moderate or severe eczema. For additional information, including advice to give patients on the use of topical calcineurin inhibitors please see section 13.5.1 Preparations for eczema.
Take clinical and drug histories of patients with atopic eczema, see NICE for details.
The distribution and appearance of the rash will be influenced by the person's age, ethnicity, duration of the rash and the presence/absence of infection. Signs of excoriation may also be present, see NICE for presentations.
Diagnose atopic eczema when the patient has an itchy skin condition plus 3 or more of the signs and symptoms, see NICE for details.
In Asian, Black Caribbean, and Black African patients, atopic eczema can affect the extensor surfaces rather than the flexures, and discoid (circular) or follicular (around hair follicles) patterns may be more common.
Use a holistic approach when assessing a patient’s atopic eczema at each consultation (holistic assessment table), taking into account:
When assessing patients with atopic eczema, identify potential trigger factors, including:
Consider food allergy in:
Consider inhalant allergy in:
Consider allergic contact dermatitis in:
Most patients do not need clinical testing for allergies.
Advise patients not to have high street or internet allergy tests because there is no evidence of their value in the management of atopic eczema.
Offer a 4-week trial of an extensively hydrolysed protein formula or amino acid formula in place of cow's milk formula for bottle-fed infants aged under 6 months with uncontrolled moderate or severe atopic eczema.
See Specialist infant formulas in primary care
Do not use diets based on unmodified proteins of other species' milk (for example, goat's or sheep's milk) or partially hydrolysed formulas for the treatment of suspected cow's milk allergy. Diets including soya protein can be offered to children over 6 months with specialist dietary advice.
Refer for specialist dietary advice children who follow a cow's-milk-free diet for more than 8 weeks.
Inform breastfeeding women that it is not known whether altering the mother's diet is effective in reducing the severity of the condition. Consider a trial of an allergen-specific exclusion diet under dietary supervision if you strongly suspect food allergy.
Management can be stepped up or down, according to the severity of symptoms, with the addition of the other treatments.
Offer patients with atopic eczema information on how to recognise flares of atopic eczema (increased dryness, itching, redness, swelling and general irritability).
Start treatment for flares of atopic eczema as soon as signs and symptoms appear and continue treatment for approximately 48 hours after symptoms subside. For information on prevention of flares see below.
When patients with atopic eczema are using emollients and other topical products at the same time of day, they should apply one product at a time and wait 20 to 30 minutes before applying the next product (they can choose which product to apply first).
Patients should only apply topical corticosteroids to areas of active atopic eczema (or eczema that has been active within the past 48 hours), which may include areas of broken skin.
Topical calcineurin inhibitors (TCI) and topical steroids should not be used at the same time on the same area of the body. However, a TCI and a topical steroid may be used on different parts of the body, for example, a TCI may be used for unresponsive facial eczema, and a topical steroid may be used for flexures.
If sleep disturbance has a significant impact, consider a trial of an age-appropriate sedating antihistamine, see Antihistamines and complementary therapies slider below.
Patients with eczema which is failing to respond to therapy or rapidly worsening may have infected eczema, see Infected eczema for management information.
Patient with areas of dry skin and infrequent itching (± small areas of redness)
Do not offer emollient bath additives to patients with atopic eczema.
Do not use topical tacrolimus and pimecrolimus for mild atopic eczema.
Emollients are the basis of management and should always be used (apply to whole body, both when the atopic eczema is clear and while using all other treatments) (see section 13.2.1 Emollients).
Mild-potency topical corticosteroids (see section 13.4 Topical corticosteroids)
Patient with areas of dry skin, frequent itching and redness (± excoriation and localised skin thickening).
Do not offer emollient bath additives to patients with atopic eczema.
Emollients are the basis of management and should always be used (apply to whole body, both when the atopic eczema is clear and while using all other treatments) (see section 13.2.1 Emollients).
Moderate-potency topical corticosteroids (see section 13.4 Topical corticosteroids)
Topical calcineurin inhibitors (see section 13.5.1 Preparations for eczema)
Dry bandages and medicated dressings (including wet wrap therapy)
Patient with widespread dry skin, incessant itching and redness (± excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation).
Do not offer emollient bath additives to patients with atopic eczema.
Emollients are the basis of management and should always be used (apply to whole body, both when the atopic eczema is clear and while using all other treatments) (see section 13.2.1 Emollients).
Potent topical corticosteroids (see section 13.4 Topical corticosteroids)
Topical calcineurin inhibitors (see section 13.5.1 Preparations for eczema)
Dry bandages and medicated dressings (including wet wrap therapy)
Phototherapy and Systemic therapy
Once the atopic eczema has been controlled, consider treating problem areas with topical corticosteroids for 2 consecutive days per week to prevent flares in patients with frequent flares (2 or 3 per month). Review this strategy within 3 to 6 months.
Patients who are taking drugs that affect the immune system may have atypical presentations of COVID‑19.
For people who have eczema and COVID-19 or suspected COVID-19, see NICE CKS: Eczema – atopic: COVID-19 for management information.
In people who are not systemically unwell, do not routinely offer either a topical or oral antibiotic for secondary bacterial infection of eczema. Take into account:
See Infected eczema for management information.
Do not routinely use oral antihistamines to manage atopic eczema.
For patients with severe atopic eczema or children with mild or moderate atopic eczema who have severe itching or urticaria, offer a 1‑month trial of a non-sedating antihistamine. If treatment is successful, think about continuing it while symptoms persist, and review every 3 months.
If sleep disturbance has a significant impact on the child or parents or carers, offer a 7‑ to 14‑day trial of an age-appropriate sedating antihistamine to children aged 6 months or over during an acute flare of atopic eczema. Think about repeating this during subsequent flares.
See 3.4.1 Antihistamines.
Explain to patients that the effectiveness and safety of the following therapies has not yet adequately been assessed in clinical trials:
See Information for Herbal treatments and homeopathy details.
Referral for specialist dermatological advice is recommended if:
See Eczema CRGs for more referral information.