When assessing patients with atopic eczema, identify potential trigger factors, including:

• irritants, for example soaps and detergents (including shampoos, bubble baths, shower gels, and washing-up liquids)
• skin infections
• contact allergens
• food allergens
• inhalant allergens

Allergy

Consider food allergy in:

• patients 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:

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

Consider allergic contact dermatitis in:

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

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.

Diet

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.

See Rapid access clinic referrals for suspected CMPA (UHP)

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.

Mild eczema

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.

First line for all patients

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).

• Offer a choice of unperfumed emollients to use every day for moisturising. This may be a combination of products or one product for all purposes. Prescribe large quantities of leave-on emollients (250g to 500g weekly)
• If current emollient causes irritation or is not acceptable, offer a different way to apply it or offer an alternative emollient.
• Review repeat prescriptions at least once a year.
• Offer advice on washing with emollients or emollient soap substitutes:
  • use leave-on emollients or emollient soap substitutes instead of soaps and detergent-based wash products
  • leave-on emollients can be added to bath water
  • children aged under 12 months should use leave-on emollients or emollient soap substitutes instead of shampoos
• Patients using shampoo should use a brand that is unperfumed and ideally labelled as suitable for eczema and should avoid washing their hair in bath water.

Additional treatments

Mild-potency topical corticosteroids (see section 13.4 Topical corticosteroids)

• Use hydrocortisone (cream or ointment) once daily for 7-14 days. 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).

Do not offer emollient bath additives to patients with atopic eczema.

First line for all patients

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).

• See ‘Mild eczema’ (above) for additional information for emollient use in eczema.

Additional treatments

Moderate-potency topical corticosteroids (see section 13.4 Topical corticosteroids)

• Use Eumovate 0.05%, Betnovate RD 0.025%, or Fludroxycortide 0.0125%
• Apply once daily for 7-14 day bursts only for flares in axillae and groins
• Apply once daily for 3-5 day bursts only for flares on face and neck

Topical calcineurin inhibitors (see section 13.5.1 Preparations for eczema)

• Recommended if eczema has not been controlled by topical corticosteroids, where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy.
• Use tacrolimus 0.1% or 0.03% ointment or pimecrolimus 1% cream:
  • Apply twice daily
  • For facial atopic eczema apply once daily for 1 month then reduce to twice per week and review at 4 months.
  • In children aged 2 to under 16 years only the 0.03% strength of topical tacrolimus should be used.
• Do not use topical calcineurin inhibitors under occlusion (bandages and dressings) for treating atopic eczema in children without specialist dermatological advice.
• Advice and guidance is available for GPs requiring specialist input when considering initiating topical calcineurin inhibitors.
• For additional information, including advice to give patients on the use of topical calcineurin inhibitors please see section 13.5.1 Preparations for eczema.

Secondary care treatments

Dry bandages and medicated dressings (including wet wrap therapy)

• Do not use occlusive medicated dressings and dry bandages to treat infected atopic eczema in children.
• Consider localised medicated dressings or dry bandages with emollients as a treatment for areas of chronic lichenified (localised skin thickening) atopic eczema.
• Consider localised medicated dressings or dry bandages with emollients and topical corticosteroids for short-term treatment of flares (7 to 14 days) or areas of chronic lichenified atopic eczema.
• When combining whole-body (limbs and trunk) occlusive dressings (including wet wrap therapy) with topical corticosteroids for atopic eczema:
  • use initially for 7 to 14 days
  • seek specialist dermatological advice before continuing this combination for longer
  • think about stopping the topical corticosteroids and continuing the dressings alongside emollients until the atopic eczema is controlled.

Severe eczema

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.

First line for all patients

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).

• See ‘Mild eczema' (above) for additional information for emollient use in eczema.

Additional treatments

Potent topical corticosteroids (see section 13.4 Topical corticosteroids)

• Use betamethasone valerate 0.1% or mometasone furoate 0.1% (cream or ointment) once daily for 7-14 day bursts only for flares in axillae and groins

Topical calcineurin inhibitors (see section 13.5.1 Preparations for eczema)

• Recommended if eczema has not been controlled by topical corticosteroids, where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy.
• Use tacrolimus 0.1% or 0.03% ointment or pimecrolimus 1% cream:
  • Apply twice daily
  • For facial atopic eczema apply once daily for 1 month then reduce to twice per week and review at 4 months.
  • In children aged 2 to under 16 years only the 0.03% strength of topical tacrolimus should be used.
• Do not use topical calcineurin inhibitors under occlusion (bandages and dressings) for treating atopic eczema in children without specialist dermatological advice.
• Advice and guidance is available for GPs requiring specialist input when considering initiating topical calcineurin inhibitors.
• For additional information, including advice to give patients on the use of topical calcineurin inhibitors please see section 13.5.1 Preparations for eczema.

Secondary care treatments

Dry bandages and medicated dressings (including wet wrap therapy)

• Do not use occlusive medicated dressings and dry bandages to treat infected atopic eczema in children.
• See 'Moderate eczema’ (above) for additional information for dry bandages and medicated dressings use in eczema

Phototherapy and Systemic therapy

• Consider phototherapy or systemic treatments for severe atopic eczema when:
  • other management options have failed or are inappropriate, and
  • there is a significant negative impact on quality of life.
• Only use phototherapy and systemic treatments under specialist dermatological supervision by staff who are experienced in its use.
• Only start phototherapy or systemic treatments in atopic eczema after assessment and documentation of severity of atopic eczema and quality of life.

Prevention of flare-ups

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.

Eczema and COVID-19

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:

• the evidence, which suggests a limited benefit with antibiotics in addition to topical corticosteroids compared with topical corticosteroids alone
• the risk of antimicrobial resistance with repeated courses of antibiotics
• the extent and severity of symptoms or signs
• the risk of developing complications, which is higher in people with underlying conditions such as immunosuppression.

See Infected eczema for management information.

Antihistamines

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.

Complementary therapies

Explain to patients that the effectiveness and safety of the following therapies has not yet adequately been assessed in clinical trials:

• homeopathy
• herbal medicine
• massage
• food supplements.

See Information for Herbal treatments and homeopathy details.

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.

See Eczema CRGs for more referral information.

• Western locality (Adults)
• Western locality (Children and Adolescents)
• South Devon and Torbay (Adults)
• South Devon and Torbay (Children and Adolescents)