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Atopic eczema is a chronic, relapsing, itchy skin condition. In infants, atopic eczema primarily involves the face, scalp, and extensor surfaces of the limbs. In children, involvement of the skin creases is more likely. Around 80% of cases occur before 5 years of age, with a high incidence of onset in the first year of life. There may be skin dryness, redness, vesicles, scaling, crusting, or thickening (lichenification) if there are chronic changes.
See:
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Note: patients with eczema which is failing to respond to therapy or rapidly worsening may have infected eczema, see below for guidance.
Emollients: see section 13.2.1 Emollients
Topical steroids: see section 13.4 Topical corticosteroids
Topical calcineurin inhibitors: see section 13.5.2 Preparations for psoriasis
Patient with areas of dry skin and infrequent itching (± small areas of redness)
Patient with areas of dry skin, frequent itching and redness (± excoriation and localised skin thickening)
Patient with widespread dry skin, incessant itching and redness (± excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation)
Referral for specialist dermatological advice is recommended if:
Identify potential trigger factors, including:
Consider food allergy in:
Consider inhalant allergy in:
Consider allergic contact dermatitis in:
Children with mild atopic eczema, reassure the child, and their parents or carers that most children do not need clinical testing for allergies.
Advise children and their parents or carers 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 6–8 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.
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.
Clinical signs of infected eczema include weeping, pustules, crusts, fever and malaise. Also atopic eczema failing to respond to therapy or rapidly worsening atopic eczema. If there are no visible signs of infection use of antibiotics (alone or with steroids) encourages resistance and does not improve healing.
Do not prescribe topical preparations for maintenance therapy.
Take swabs from infected lesions of atopic eczema only if you suspect microorganisms other than Staphylococcus aureus or if you think antibiotic resistance is relevant.
Explain that topical treatments in open containers can be contaminated with microorganisms and act as a source of infection. New supplies should be obtained at the end of treatment for infected atopic eczema.
Use oral antibiotics plus appropriate potency topical corticosteroid
If infection responds poorly to antibiotic treatment, consider results of swabs and treat according to sensitivities, or seek specialist advice.
Flucloxacillin
Doxycycline
Clarithromycin
Use combined topical antibiotic/corticosteroid preparation for maximum of 2 weeks only.
Do not prescribe topical preparations for maintenance therapy.
Fusidic acid resistance is a widespread problem due to inappropriate use. Swabs should be taken at the same time as prescribing a fusidic acid based product.
Fucidin H® cream (fusidic acid 2% / hydrocortisone 1%)
Fucibet® cream (fusidic acid 2% / betamethasone valerate 0.1%)
Trimovate® cream (clobetasone / oxytetracycline / nystatin)
See section 13.4 Topical corticosteroids
Suspect if
Management
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