g logo ipb green

What is eczema?

Eczema (also known as atopic eczema or atopic dermatitis) is a common, chronic, relapsing, inflammatory skin disorder. The skin function is impaired leading to porous and dry skin that easily becomes inflamed, susceptible to infection and itchy. Chronically scratched skin may become thickened (lichenified).

Assessment

An holistic approach is essential:

  • Onset under 2 years of age; presence of an itchy rash
  • Relevant family/social history – eczema, asthma, hayfever, smokers, pets
  • Impact on quality of life for child and family (sleep deprivation, schooling, family dynamics)
  • Adverse effects on child such as failure to thrive
  • What treatments are being and have been used; how long for; what helped and what did not
  • Parental expectations and specific questions should be documented/addressed
  • Distribution of eczema and other clinical signs eg generally dry skin, weeping, crusting.

Management - ABC rule

A  A void triggers; soaps or anything that bubbles or lathers, cigarette smoke, irritant clothing.

B  B land moisturisers which are fragrance-free are an absolute essential part of treatment. Ideally applied 3-4 times daily, prescribe adequate quantities (at least 250-500g/week); patient choice improves concordance; bath additives are not recommended; use emollients to wash (apply before wetting the skin); ideally wash hair over the sink to avoid shampoo on skin causing irritation.

C  C ontrol inflammation – match potency of topical steroids (mild, moderate, potent) to the severity of eczema and anatomical site. Use once daily until eczema is settled (usually 1-6 weeks), then decrease to twice weekly use for maintenance. Step-up use to daily during a flare, then wean back down for maintenance therapy (reduces frequency of flares). Topical calcineurin inhibitors are useful as second line treatment. Tacrolimus 0.1% (off-license) can be used for children and is particularly useful when applied to delicate sites ie flexures, eyelids. Oral steroids should not normally be prescribed for children with eczema in primary care without specialist advice. There is unjustified TOPICAL steroid phobia amongst healthcare professionals; there is robust evidence of the safety in long-term use in eczema.

Other considerations

  • Investigation – no routine role for allergy testing or exclusion diets unless failure to thrive (under 6 months of age) or obvious triggers in the history
  • No evidence for the use of non-sedating antihistamines in eczema but short-term use of sedating antihistamines may improve sleep
  • No evidence for use of prescribed garments
  • Direct to patient support groups e.g. National Eczema Society and/or other eczema websites; offer written/documented advice to families
  • Complications – infection (bacterial or viral) – use of short-term antibiotics or antivirals are appropriate after a swab has been taken if infection is suspected. Avoid long-term use of combination topical agents (eg clotrimazole or fucidic acid with a topical steroid)
  • In families with an atopic eczema history, start emollient therapy at birth as this might help reduce the incidence of eczema
  • There is no compelling evidence for the use of alternative therapies.

When to refer

  • Diagnostic uncertainty
  • Failure to respond to treatment
  • Steroid atrophy/overuse of topical steroids
  • Eczema herpeticum or suspected bacterial infection (eg streptococcal) not responding to treatment
  • Severe eczema or systemically unwell child.

Allergy and diet

Infants under 6 months with moderate to severe eczema not responding to optimal topical treatment could be considered for a trial of 4-8 weeks of extensively hydrolysed protein formula whilst awaiting referral to Dermatology. Exclusion diets should not be trialled without dietician guidance or specialist review.

Table 1: Clinical features and specific treatment of four types of paediatric eczema
 Clinical featuresSpecific treatment
Infant Facial Eczema
  • Moderate to severe exudative facial eczema unresponsive to hydrocortisone
  • In difficult facial eczema consider moderate potency steroid e.g. Eumovate® for 5 days
  • For persistent eczema consider 0.1% tacrolimus (off-licence)
Eczema Herpeticum
  • Punched-out vesicles and lesions that have the same shape and configuration (i.e. are monomorphic)
  • Oral aciclovir for localised eczema herpeticum (review in 48-72 hours but provide careful safety-netting and see if worsens ASAP)
  • Admit under paediatrics for intravenous therapy if unwell/extensive 
Discoid Eczema
  • Single/multiple round shaped patches and lesions, sometimes weepy
  • Often misdiagnosed as impetigo, or more commonly, a fungal infection. Scrape any scale and send mycology if in doubt
  • Tends to need more prolonged courses of moderate to potent topical steroids (for up to 6 weeks) and recurrence is common
Chronic Lichenified Eczema
  • Thickened excoriated skin with increased skin markings
  • Potent steroids plus occlusion (e.g. paste bandages or clingfilm wrapped around a limb at night) once daily for up to 2 weeks, then review
  • Step down accordingly if improvement is noted

Want to learn more about this guideline?

GinP G Logo small

Read the related Guidelines in Practice article

Full guidelines available from: Primary Care Dermatology Societywww.pcds.org.uk/ee/images/uploads/general/Paediatric_Eczema_Pathway-web.pdf

First included: September 2019.

Further information: National Eczema Societywww.eczema.org