Management of eczema

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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

Mild eczema

Patient with areas of dry skin and infrequent itching (± small areas of redness)

1. Emollients
2. Mild potency topical steroid (can be used on all areas including face and neck)

Moderate eczema

Patient with areas of dry skin, frequent itching and redness (± excoriation and localised skin thickening)

1. Emollients
2. Moderate potency topical steroid (use for 7-14 day bursts only for flares in axillae and groins, and for 3-5 day bursts only for flares on face and neck)
3. Topical calcineurin inhibitors
4. Secondary care treatments
   • Bandages / garments
   • Phototherapy
   • Systemic therapy

Severe eczema

Patient with widespread dry skin, incessant itching and redness (± excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation)

1. Emollients
2. Potent topical steroid for 7-14 day bursts (do not use on face, neck, axillae, groins, or elbow and knee flexures). Do not prescribe potent topical steroids in children under 12 months, or very potent topical steroids under 16 years of age in primary care without specialist dermatological advice.
3. Topical calcineurin inhibitors
4. Secondary care treatments
   • Bandages / garments
   • Phototherapy
   • Systemic therapy

Referral for specialist dermatological advice is recommended if:

• the diagnosis is, or has become, uncertain
• management has not controlled the atopic eczema satisfactorily based on a subjective assessment by the child, parent or carer (for example the child is having 1–2 weeks of flares per month or is reacting adversely to many emollients)
• atopic eczema on the face has not responded to appropriate treatment
• the child or parent/carer may benefit from specialist advice on treatment application (for example, bandaging techniques)
• contact allergic dermatitis is suspected (for example, persistent atopic eczema or facial, eyelid or hand atopic eczema)
• the atopic eczema is giving rise to significant social or psychological problems for the child or parent/carer (for example, sleep disturbance, poor school attendance)
• atopic eczema is associated with severe and recurrent infections, especially deep abscesses or pneumonia.

Trigger factors

Identify potential trigger factors, including:

• irritants (such as soap and detergents)
• skin infections
• contact allergens
• food allergens
• inhaled allergens

Allergy

Consider food allergy in:

• children who have reacted immediately to a food
• infants and young children with moderate or severe uncontrolled atopic eczema, particularly with gut dysmotility or failure to thrive

Consider inhalant allergy in:

• children with seasonal flares of atopic eczema
• children with associated asthma and rhinitis
• children over 3 years with atopic eczema on the face

Consider allergic contact dermatitis in:

• children with an exacerbation of previously controlled atopic eczema
• children who react to topical treatments

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.

Diet

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.

Extensive bacterial infection

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

• Adult: 500mg every 6 hours for 7 days
• Child
  • 2–10 years: 125–250mg 4 times daily
  • 10–18 years: 250–500mg 4 times daily

Penicillin-allergy

Doxycycline

• 200mg single dose stat, then 100mg daily for total of 7 days
• Not be used in patients aged under 12 years

3rd line

Clarithromycin

• Adult: 500mg every 12 hours for 7 days
• Child 1 month–12 years:
  • Body-weight under 8 kg 7.5mg/kg twice daily for 7 days
  • Body-weight 8–11 kg 62.5mg twice daily for 7 days
  • Body-weight 12–19 kg 125mg twice daily for 7 days
  • Body-weight 20–29 kg 187.5mg twice daily for 7 days
  • Body-weight 30–40 kg 250mg twice daily for 7 days
• Child 12–18 years 250mg twice daily for 7 days

Localised bacterial infection

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%)

• Apply twice daily (maximum 14 days)

Fucibet® cream (fusidic acid 2% / betamethasone valerate 0.1%)

• Apply twice daily (maximum 14 days)

For skin flexures and genital area

Trimovate® cream (clobetasone / oxytetracycline / nystatin)

• Apply twice daily (maximum 14 days)

See section 13.4 Topical corticosteroids

Reducing bacterial infections

• Ensure appropriate potency of topical corticosteroid is being used. Inadequate control of the underlying atopic eczema is the most frequent cause of repeated infections.
• Consider antiseptic emollients / shower / bath preparations (e.g. Dermol® range) to reduce bacterial colonisation.

Eczema herpeticum

Suspect if

• areas of rapidly worsening, painful eczema
• possible fever, lethargy or distress
• clustered blisters (often in one area) consistent with early-stage cold sores
• punched-out erosions (usually 1–3 mm) uniform in appearance which may coalesce.

Management

• Take viral swabs
• Treat with aciclovir tablets
• If you suspect secondary bacterial infection, start treatment with appropriate systemic antibiotics as well.
• Refer immediately (same day) for specialist dermatological advice