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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.
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 should include:
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.|
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|
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.
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|
|Mild potency topical steroids||Moderate potency topical steroids||Potent topical steroids|
|Topical calcineurin inhibitors (if aged 2 years and above)||Topical calcineurin inhibitors (if aged 2 years and above)|
Topical calcineurin inhibitors, bandages, phototherapy and systemic therapy would usually be started in secondary care.
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.
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 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.
Immediate (same day) referral:
Urgent referral (within 2 weeks)
Paediatric dermatology and paediatric allergy work closely together
Referral to paediatric allergy clinic may also be necessary
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This guideline has been signed off by the Western Locality on behalf of NEW Devon CCG.
Publication date: January 2017