Atopic eczema in children: management of atopic eczema
in children from birth up to the age of 12 years
Scope of the guidance
This item provides guidance on best practice
in:
- diagnosis and assessment of the impact of atopic eczema in
children
- management during and between flare-ups of atopic eczema
- information and education for children and their families about
atopic eczema
Atopic eczema is a chronic, relapsing, and itchy inflammatory
skin condition. In the acute stage, eczematous lesions are
characterised by poorly defined erythema with surface change
(oedema, vesicles and weeping). In the chronic stage, lesions are
marked by skin thickening (lichenification). Atopic eczema affects
about 15-20% of school age children at sometime. (See Clinical
Evidence Handbook in Further Reading).
Source
National Institute for Clinical Excellence. Atopic eczema in
children: management of atopic eczema in children from birth up to
the age of 12 years. NICE Clinical Guidelines 57.
London: NICE, 2007.
www.nice.org.uk/nicemedia/pdf/CG057NICEguideline.pdf
Key points
1. Diagnosis
- A diagnosis of atopic eczema in a child is
made if there is an itchy skin rash plus three or more of:
o
visible dermatitis in skin creases
o
history of flexural dermatitis
o
history of dry skin
o
history of asthma or allergic rhinitis
o
onset of the rash below the age of two years
- In Asian, black Caribbean and black African
children atopic eczema often affects the extensor surfaces; discoid
or follicular patterns may be more common.
2. Assessment
o
pattern and severity
o
previous treatments and response to those treatments
o
possible trigger factors
o
impact of the disease on the child / family e.g. on everyday
activities or sleep. There is not always a direct
relationship between severity of eczema and its impact on a child’s
quality of life.
3. Trigger Factors
- Common trigger factors
include:
o
irritants e.g. soaps and detergents
o
skin infections
o
contact allergens, especially if the eczema responds to topical
treatment
o
inhaled allergens, especially if the eczema is seasonal or is
associated with asthma or allergic rhinitis
- Advise parents that most children with
eczema do not need allergy testing.
4. Treatments
- Treatment of atopic eczema should be based on a
‘stepped-care plan’ where treatments are stepped up or down
depending on your assessment of the state of the child’s skin.
o
Step 1: clear skin. Use emollients only.
o
Step 2: mild – areas of dry skin, and infrequent itching. Use
emollients alone or combined with a topical steroid of mild
potency.
o
Step 3: moderate – areas of dry skin, frequent itching and
redness. Use emollients with a topical steroid of moderate
potency (body: 7-14 days, face 3-5 days use), bandages, (then a
topical calcineurin inhibitor such as tacrolimus - but only
initiated under specialist dermatological supervision).
o
Step 4: severe – widespread areas of dry skin, incessant itching,
redness. Use emollients, potent topical steroids (moderate
potency on the face or neck), bandages, (then tacrolimus,
phototherapy or systemic treatment – but only initiated under
specialist dermatological supervision).
o
are the best treatment when the diagnosis of atopic eczema is
clear
o
should be prescribed in large quantities.
o
can be used instead of soap, and instead of shampoo for
infants.
- Topical steroids: potency should be tailored
to the severity of the child’s atopic eczema across their
body:
o
use mild potency for mild atopic eczema
o
use moderate potency for moderate atopic eczema
o
use potent topical corticosteroids for severe atopic eczema
o
use mild potency for the face and neck except short term (3-5 days)
use of moderate potency for severe flares
o
use moderate or potent corticosteroids for short periods only (7-14
days) for flares in vulnerable sites such as axillae and groin
o
do not use very potent corticosteroids in children without
specialist dermatological advice
o
if a mild or moderate topical steroid has not controlled the eczema
within 7-14 days, consider whether a secondary bacterial or viral
infection might be present. If a potent steroid fails to work
over a short time, refer the child to a dermatologist.
o
is a second-line treatment and should only be started by doctors
with a special interest in dermatology.
o
should not be used under bandages or dressings, without
dermatological advice.
o
An association has been suggested between tacrolimus and skin
cancer (see Clinical Evidence Handbook in Further Reading)
o
use on top of emollients, or on top of emollients plus topical
steroid.
o
use when other treatments for eczema have failed.
o
should be initiated and organised by a specialist
dermatologist.
o
a one month trial of a non-sedating antihistamine can be used for
children with severe atopic eczema, or children with mild /
moderate eczema with severe itching or urticaria. Continue if
the trial is successful.
o
a 1-2 week course of a sedating antihistamine can be used for an
acute flare of dermatitis, where the child’s sleep is being
affected.
o
give parents information about how to recognise flares.
start treatment for flare-ups as soon as there
are symptoms or signs
5. Infections
- Remind parents to beware that containers of
topical treatment can become contaminated which could lead to
re-infection. For this reason, such containers should be replaced
once a skin infection has been treated.
o
tell parents of the signs and symptoms to watch out for: weeping,
pustules, crusting and sudden worsening of the rash.
o
swab if you suspect a bacteria other than Staph. aureus or if you
think there might be antibiotic resistance.
o
treat with topical antibiotics (can be combined with topical
steroids) for localised infection, or systemic antibiotics for
widespread infection.
o
in all children with eczema with a severe flare consider if the
skin is infected with herpes simplex – that is, eczema herpeticum.
If so, treat as an emergency and consider prescribing systemic
aciclovir immediately and refer for an emergency dermatological
opinion.
o
if the rash involves the skin around the eyes, you may need you may
need to prescribe prophylactic ocular acyclovir and consider
referral for an emergency opthalmological opinion too.
o
if you think that there might be secondary bacterial infection as
well, then start systemic antibiotics.
6. Referral to dermatological specialist
- Emergency referral if you suspect eczema
herpeticum
- Urgent (within two weeks) if the eczema is
severe and has failed to respond to topical therapy or treatment of
bacterial infection has failed.
o
the diagnosis is uncertain
o
standard treatment has not controlled eczema
o
you suspect contact dermatitis
o
there is recurrent infection of the eczema
o
the child’s eczema is causing significant social or psychological
problems.
Practical tips for the busy GP >>
EGP 1. May 2008