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Atopic Eczema in children
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.
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
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.
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.
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-South Devon & Torbay-Children's & Adolescent Services- Devon ICB - 15N
Referral to Paediatric Allergy
e-Referral Service Selection
- Specialty: Children & Adolescent
- Clinic Type: Allergy
- Service: DRSS-South Devon & Torbay-Children's & Adolescent Services- Devon ICB - 15N
Referral Forms
Patient Information
Evidence
NICE Guidelines - Atopic eczema in under 12s: diagnosis and management
Pathway Group
This guideline has been signed off on behalf of NHS Devon.
Publication date: August 2017
Reviewed: April 2024
