Guidelines
Investigation and Diagnosis
Clinical Diagnosis
- Investigations are NOT necessary for establishing diagnosis, but may be useful for excluding differentials
Clinical diagnostic criteria:
- Itchy skin, AND
- ≥3 of the following:
- Onset <2 y/o (this criterion should not be used in <4 y/o)
- Visible flexural eczema involving the skin creases (or in ≤18 months: visible eczema on the cheeks and/or extensor areas)
- Personal history of flexural eczema (or in ≤18 months: history of eczema on the cheeks and/or extensor areas)
- Personal history of dry skin in the last 12 months.
- Personal history of asthma or allergic rhinitis (or in <4 y/o: this criterion counts if there is family history of atopic disease in a first-degree relative)
NICE notes thatthese criteria apply to all ages, social classes, and ethnic groups. However, in children of Asian, black Caribbean, and black African ethnic groups, atopic eczema can affect the extensor surfaces rather than the flexures, and discoid (circular) or follicular (around the hair follicles) patterns may be more common.
Severity Assessment
The following categorisation is important in guiding management:
| Category | Appearance | Psychological impact |
|---|---|---|
| Mild |
|
Little impact on everyday activities, sleep and psychosocial well-being |
| Moderate |
|
Moderate impact on everyday activities, sleep and psychosocial well-being, and frequently disturbed sleep |
| Severe | Widespread areas of dry skin with:
|
Severe limitations of everyday activities and psychosocial functioning, and loss of sleep every night |
| Infected |
|
n/a |
Management
General Self-Care Advice
For all patients, includes:
- Trigger avoidance
-
Clothing: avoid synthetic fibres (prefer cotton)
-
Soaps/detergents: avoid irritants → use emollient soap substitutes
-
Environment: avoid animals if a trigger; keep rooms cool
-
- Manage itch & scratching
-
Avoid scratching → rub instead
-
Keep nails short
-
Anti-scratch mittens for babies
-
- Educate on flare-recognition
Pharmacological Management
Management approach is based on the severity category (see above).
Stepped treatment options for atopic eczema:
| Mild eczema | Moderate eczema | Severe eczema |
|---|---|---|
| Emollients | Emollients | Emollients |
| Mild E.g., hydrocortisone 1% potency topical corticosteroids |
Moderate E.g., betamethasone valerate 0.025% or clobetasone butyrate 0.05% potency topical corticosteroids* |
Potent E.g., betamethasone valerate 0.1% topical corticosteroids* |
| n/a | Topical calcineurin inhibitors (tacrolimus or pimecrolimus)** | Topical calcineurin inhibitors (tacrolimus or pimecrolimus)** |
| n/a | Bandages** | Bandages** |
| n/a | n/a | Phototherapy** |
| n/a | n/a | Systemic therapy (e.g. oral corticosteroid, cyclosporin, azathioprine)** |
| * For delicate areas (e.g. face and flexures), start with a corticosteroid that is one potency class lower and only step up if ineffective (i.e. start with mild potency in moderate eczema, and moderate potency in severe eczema). | ||
| ** Usually only prescribed by a specialist (e.g. GP with a specialist interest in dermatology, a dermatologist, or a paediatrician). | ||
The following sections restructure the management of each eczema severity into
- 1) Flare Management
- 2) Maintenance Therapy
Mild Eczema
- Regular emollient use
Some good prescribing points regarding emollients in eczema
- Ointments are preferable for dry skin
- Emollients without active ingredients are preferred
- Emollient with pump dispenser (versus dipping fingers into cotnainer) is preferred to minimise risk of bacteria contamination
- Flare: consider mild topical corticosteroid (e.g. hydrocortisone 1%)
- To be continued for 48 hours after flare is controlled
Active follow-up is rarely required for mild eczema, unless the person or carer requests it
Moderate Eczema
Acute Flare Management
- Moderately potent topical corticosteroid (e.g. betamethasone valerate 0.025% or clobetasone butyrate 0.05%)
- To be continued for 48 hours after flare is controlled
- For delicate areas of skin (face and flexures): consider starting with a mild potency topical corticosteroid (e.g. hydrocortisone 1%) and only increase to moderate potency if necessary and aim for maximum of 5 days use
- Continue emollients (but apply at different times from the steroid)
- Consider localised medicated dressings / dry bandages with emollients and topical corticosteroid for 7-14 days
- Only to be started by a healthcare professional trained in their use
If severe itch / urticaria
- Consider 1-month trial of non-sedating antihistamine (e.g. cetirizine, loratadine, fexofenadine)
- If itching is affecting sleep: consider short course (maximum 2 weeks) of sedating antihistamine (e.g. chlorphenamine)
Maintenance Therapy
- Regular emollient use
Some good prescribing points regarding emollients in eczema:
- Ointments are preferable for dry skin
- Emollients without active ingredients are preferred
- Emollient with pump dispenser (as opposed to placing finger inside container) is preferred to minimise risk of bacteria contamination
- Consider preventive/maintenance treatment
- 1st line: topical corticosteroid as ‘step down approachStart with lowest potency topical corticosteroid Usually a potency class down from what is used during a flare‘ or ‘intermittent treatmentConsider either one: - Weekend therapy: steroid to be used on 2 consecutive days per week - Twice weekly therapy: steroid to be used twice a week (e.g. every 3-4 days)‘
- 2nd line: topical calcineurin inhibitors (tacrolimus, pimecrolimus)
- Only to be prescribed in secondary care
- Only used in >2 y/o
- Consider localised medicated dressings / dry bandages with emollients to treat areas of chronic lichenified skin
Severe Eczema
Acute Flare Management
- Potent topical corticosteroid (e.g. betamethasone valerate 0.1%)
- To be continued for 48 hours after flare is controlled
- For delicate areas of skin (face and flexures): consider starting with a moderate potency topical corticosteroid (e.g. betamethasone valerate 0.025%, clobetasone butyrate 0.05%) aiming for a maximum of 5 days use
- Continue emollients (but apply at different times from the steroid)
- Consider localised medicated dressings / dry bandages with emollients and topical corticosteroid for 7-14 days
- Only to be started by a healthcare professional trained in their use
- Consider oral corticosteroids
Children <16 yrs should be referred before starting treatment with oral steroids.
A dose of 30mg prednisolone taken in the morning for 1 week is generally considered sufficient.
(short-course)- For severe, extensive eczema causing psychological distress
If severe itch / urticaria
- Consider 1-month trial of non-sedating antihistamine (e.g. cetirizine, loratadine, fexofenadine)
- If itching is affecting sleep: consider short course (maximum 2 weeks) of sedating antihistamine (e.g. chlorpheniramine)
Do NOT use potent corticosteroids in children under 12 months old, or very potent corticosteroids in children of any age, without specialist dermatological advice.
Maintenance Therapy
- Regular emollient useSome good prescribing points regarding emollients in eczema: - Ointments are preferable for dry skin - Emollients without active ingredients are preferred - Emollient with pump dispenser is preferred to minimise risk of bacteria contamination (generous amount to be used 4 times daily on the entire body), even when symptoms are controlled
- Consider preventive/maintenance treatment
- 1st line: topical corticosteroid as ‘step down approachStart with lowest potency topical corticosteroid Usually a potency class down from what is used during a flare‘ or ‘intermittent treatmentConsider either one: - Weekend therapy: steroid to be used on 2 consecutive days per week - Twice weekly therapy: steroid to be used twice a week (e.g. every 3-4 days)‘
- 2nd line: topical calcineurin inhibitors (tacrolimus, pimecrolimus)
- Only to be prescribed by secondary care
- Only used in >2 y/o
- Consider localised medicated dressings / dry bandages with emollients to treat areas of chronic lichenified skin
Further Secondary Care Therapy
If above interventions have failed, consider:
- Phototherapy
- Systemic immunosuppressants (e.g. cyclosporin, azathioprine)
Infected Eczema
Admission to hospital indicated if eczema herpeticum is suspected
DO NOT routinely offer topical / oral antibiotic for secondary bacterial infection of eczema, unless systemically unwell:
- If antibiotic is offered, 1st line: flucloxacillin (alternative: clarithromycin)
- For localised infection: consider topical fusidic acid
Episodes of infected eczema usually co-exist with a flare and will require concomitant treatment as described above.
Dry bandages and medicated dressings (including wet wrap therapy) should NOT be used to treat infected atopic eczema.