​Atopic Eczema

Scope

Atopic eczema is a chronic inflammatory itchy skin condition. It is typically an episodic disease of exacerbations (flares, which may occur as frequently as two to three/month) and remissions. In some cases it may be continuous.

Atopic eczema often has a genetic component that leads to the breakdown of the skin barrier. This makes the skin susceptible to trigger factors, including irritants and allergens, which can make eczema worse.

Out of scope

It does not cover children with infantile seborrhoeic eczema, juvenile plantar dermatosis, primary irritant and allergic contact dermatitis, napkin dermatitis, pompholyx or photosensitive eczema, except when these conditions occur in association with atopic eczema.

​Assessment

Healthcare professional should adopt a holistic approach when assessing a child's atopic eczema at each consultation, taking into account the severity of the atopic eczema and the child's quality of life, including everyday activities and psychosocial wellbeing.

History and Examination

History should include:

  • time of onset, pattern and severity of atopic eczema
  • response to previous and current treatments
  • impact of atopic eczema on the child and their parents/carers
  • personal of family history of atopic diseases
  • history of diet manipulation
  • growth and development
  • identify potential trigger factors including:
    • irritants, e.g. soaps and detergents (shampoos, bubble baths and shower gels)
    • skin infections
    • inhalant and contact allergens such as moulds, pets, pollen, and chemicals or metals
  • zinc deficiency
  • food allergy should be considered in children with atopic eczema who have reacted to a food with immediate symptoms and in infants and young children with moderate or severe atopic eczema that has not been controlled with optimum management, particularly if associated with colic, vomiting, persistent loose stool or failure to thrive.

Signs and Symptoms

Assessment of severity of eczema (see chart below)

Skin/physical severity Impact on quality of life and psychosocial wellbeing
Clear Normal skin None No impact on quality of life
Mild Areas of dry skin, infrequent itching (with and without small areas of redness) Mild Little impact on everyday activities and sleep.
Moderate Areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening) Moderate Moderate impact on everyday activities and wellbeing, frequently disturbed sleep.
Severe Widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation)
Severe Severe impact on everyday activities and wellbeing, and nightly loss of sleep

Differential Diagnoses

Infantile seborrhoeic eczema, primary irritant and allergic contact dermatitis and napkin dermatitis

​Red Flags

Eczema Herpeticum – Signs of eczema herpeticum are areas of rapidly worsening, painful eczema, clusters of blisters and punched out erosions, fever and lethargy. If eczema herpeticum is suspected aciclovir should be started immediately and referred for same-day specialist dermatological advice.

​Investigations

Microscopy, culture and sensitivity (MC&S) swabs should only be taken from infected lesions of atopic eczema if other micro-organisms other than Staphylococcus aureus and streptococcus are suspected. Flucloxacillin should be used as first line treatment.

Formulary Chapter 13 Skin

​Management

Eczema education is very important and healthcare professionals should be providing it in verbal or written forms and practical demonstrations.

Healthcare professionals should use a stepped approach for managing atopic eczema in children. This means tailoring the treatment step to the severity of the atopic eczema. Management can be stepped up and down, according to the severity of symptoms. See table below.

Mild atopic eczema Moderate atopic eczema Severe atopic eczema
Emollients Emollients Emollients
Mild potency topical steroids Moderate potency topical steroids Potent topical steroids
Topical calcineurin inhibitors (if aged 2 yrs.and above) Topical calcineurin inhibitors (if aged 2 yrs and above)
Bandages Bandages
Phototherapy
Systemic therapy

Topical calcineurin inhibitors, bandages, phototherapy and systemic therapy would usually be started in secondary care.

Emollients

Emollients should always be used even when the eczema is clear. These should be prescribed in large quantities (250-500g/week).

Healthcare professionals should offer children and parents/carers information on how to recognise flares of atopic eczema, (increased dryness, itching, redness, swelling and general irritability). They should give clear instructions on how to manage flares according to the stepped-care plan.

Steroids

Topical steroids should be tailored to the severity of the child's atopic eczema, see table above.

Treatments for flares of atopic eczema should be started as soon as signs and symptoms appear and continued for approximately 48 hours after symptoms subside.

Use mild potency steroids for face and neck, except for short-term (3-5 days) use of moderate potency for severe flares.

Use moderate or potent preparations for short periods (7-14 days) for flares in vulnerable sites such as axillae and groin.

Do not use very potent preparations in children without specialist dermatological advice.

Healthcare professional should consider treating problem areas of atopic eczema with topical steroids for 2 consecutive days a week (i.e. Saturday and Sunday), once the eczema has been controlled, this should be assessed at 6 months to assess effectiveness).

Topical calcineurin inhibitors

Topical calcineurin inhibitors are an option for the second-line treatment of moderate and severe eczema for children aged 2 years and above that has not responded to topical steroids, where there is risk of adverse effects of topical steroid use, particularly skin atrophy. It can be used for facial eczema in children that require long-term or frequent use of mild topical steroids.

Healthcare professionals should offer children and parents/carers information on how to recognise the symptoms and signs of bacterial infection: weeping, pustules, crusts, eczema failing to respond to therapy, rapidly worsening eczema, fever and malaise and particularly eczema herpeticum (see red flag). Clear information should be provided on how to access treatment when a child's eczema becomes infected.

Microscopy, culture and sensitivity (MC&S) swabs should only be taken from infected lesions of atopic eczema if other micro-organisms other than Staphylococcus aureus and streptococcus are suspected. Flucloxacillin should be used as first line treatment.

Formulary Chapter 13 Skin

​Referral

Referral Criteria

For specialist dermatological advice

Immediate (same day) referral:

  • if eczema herpeticum is suspected.

Urgent referral (within 2 weeks)

  • State the reasons for 2 week referral and the dermatology department will try to ensure they are seen in a timely fashion
    • if treatment of bacterially infected eczema has failed
    • eczema is severe and has not responded to optimum topical therapy after 1 week

Routine referral

  • if the diagnosis is, or has become uncertain.
  • eczema on the face has not responded to appropriate treatment.
  • for specialist advice on treatment application i.e. bandaging, wet wrapping.
  • contact allergic dermatitis is suspected i.e. facial, eyelid or hand eczema.
  • atopic eczema is giving rise to significant social or psychological problems for the child or parent/carer i.e. poor sleep, poor school attendance.
  • atopic eczema with severe or recurrent infections.
  • management has not controlled the atopic eczema satisfactory based on a subjective assessment by the child, parent or carer i.e. the child is having 1-2 weeks of flares per month.

Paediatric dermatology and paediatric allergy work closely together

Referral to paediatric allergy clinic may also be necessary

  • if concurrent food allergies are suspected via the history.
  • if faltering growth is present in infants in conjunction with severe eczema.
  • egg allergy and moderate-severe eczema are present in infants under 1 year; refer to paediatric allergy clinic for weaning advice as well as paediatric dermatology for skin care.

Referral Instructions

Referral to Paediatric Dermatology

e-Referral Service Selection

  • Specialty: Children & Adolescent
  • Clinic Type: Dermatology
  • Service: DRSS-Eastern-Child & Adolescent Services-Devon CCG - 15N
Referral to Paediatric Allergy

e-Referral Service Selection

  • Specialty: Children & Adolescent
  • Clinic Type: Allergy
  • Service: DRSS-Eastern-Paediatrics- Devon CCG-15N

Referral Forms

DRSS referral form

​Supporting Information

Patient Information

National Eczema Society

Evidence

NICE Guidelines - Atopic eczema in under 12s: diagnosis and management

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG.

Publication date: 6 July 2016

 

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