Latest Guidance Updates
January 2023: new information added with examples of topical calcineurin inhibitors and how often to apply them, in the section Other Considerations. In the same section, the recommendation on antihistamines has changed, and it is now advised not to prescribe garments routinely.
This updated Guidelines summary covers information on the assessment, management, treatment, and referral criteria of paediatric eczema, from the Primary Care Dermatology Society's primary care treatment pathway.
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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).
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, for example, generally dry skin, weeping, crusting.
Management—ABC RuleA Avoid triggers; soaps or anything that bubbles or lathers, cigarette smoke, irritant clothing.
B Bland moisturisers which are fragrance-free are an absolute essential part of treatment. Ideally applied 3–4 times daily, prescribe adequate quantities (at least 250–500 g/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 Control 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, and can be used for children. Topical calcineurin inhibitors are helpful, particularly when applied to delicate sites, that is, flexures, eyelids, and the face. 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. Using daily for flare and twice-weekly for maintenance improves flare intensity and frequency, and reduces overall steroid use.
- 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 routine use of antihistamines in improving eczema, but short-term use of sedating antihistamines may temporarily improve sleep. Some children may benefit with antihistamine treatment if skin worsens in hayfever season
- Do not prescribe garments routinely; they may help a selective group of eczema patients, such as severe eczema
- Direct to patient support groups, for example, 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 (for example, clotrimazole or fucidic acid with a topical steroid)
- There is no compelling evidence for the use of alternative therapies
- Examples of topical calcineurin inhibitors are:
- pimecrolimus 1% cream (Elidel; licensed from 3 months; potency similar to 1% hydrocortisone)
- tacrolimus 0.03% and 0.1% ointments (Protopic; 0.03% licensed from age 2 and potency of clobetasone, and 0.1%, licensed from age 16; off-license can be used in children under 16; potency of mometasone furoate)
- Do warn that one in 10 may suffer transient stinging to the skin, and this usually settles within a week
- Prescribing a topical steroid to use concomitantly for a week, or using moisturiser before applying, can often reduce stinging. Apply twice daily. When eczema is controlled, use once a day, twice weekly, similar to topical steroid regimes.
When to Refer
- Diagnostic uncertainty
- Failure to respond to treatment
- Steroid atrophy/overuse of topical steroids
- Eczema herpeticum or suspected bacterial infection (for example, streptococcal) not responding to treatment
- Severe eczema or systemically unwell child.
Allergy and Diet
- Infants under 6 months of age 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 Features||Specific Treatment|
|Infant facial eczema|
|Chronic lichenified eczema|