Key priorities for implementation

Key priorities for implementation

Assessment of severity, psychological and psychosocial wellbeing and quality of life

  • Healthcare professionals 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 sleep, and psychosocial wellbeing (see table below). There is not necessarily a direct relationship between the severity of the atopic eczema and the impact of the atopic eczema on quality of life.

Holistic assessment

Skin/physical severity

Impact on quality of life and psychosocial wellbeing

Clear

Normal skin, no evidence of active atopic eczema

None

No impact on quality of life

Mild

Areas of dry skin, infrequent itching (with or without small areas of redness)

Mild

Little impact on everyday activities, sleep and psychosocial wellbeing

Moderate

Areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening)

Moderate

Moderate impact on everyday activities and psychosocial wellbeing, frequently disturbed sleep

Severe

Widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation)

Severe

Severe limitation of everyday activities and psychosocial functioning, nightly loss of sleep

Identification and management of trigger factors

  • When clinically assessing children with atopic eczema, healthcare professionals should seek to identify potential trigger factors including:

    • irritants, for example soaps and detergents (including shampoos, bubble baths, shower gels and washing-up liquids)

    • skin infections

    • contact allergens

    • food allergens

    • inhalant allergens.

  • Healthcare professionals should consider a diagnosis of food allergy in children with atopic eczema who have reacted previously to a food with immediate symptoms, or in infants and young children with moderate or severe atopic eczema that has not been controlled by optimum management, particularly if associated with gut dysmotility (colic, vomiting, altered bowel habit) or failure to thrive.

Treatment

Stepped approach to management

  • 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. Emollients should form the basis of atopic eczema management and should always be used, even when the atopic eczema is clear. Management can then be stepped up or down, according to the severity of symptoms, with the addition of the other treatments listed in the table below.

Mild atopic eczema

Moderate atopic eczema

Severe atopic eczema

Emollients

Emollients

Emollients

Mild potency topical corticosteroids

Moderate potency topical corticosteroids

Potent topical corticosteroids

Topical calcineurin inhibitors

Topical calcineurin inhibitors

Bandages

Bandages

Phototherapy

Systemic therapy

  • Healthcare professionals should offer children with atopic eczema and their parents or 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, and prescribe treatments that allow children and their parents or carers to follow this plan.

Emollients

  • Healthcare professionals should offer children with atopic eczema a choice of unperfumed emollients to use every day for moisturising, washing and bathing. This should be suited to the child's needs and preferences, and may include a combination of products or one product for all purposes. Leave-on emollients should be prescribed in large quantities (250–500 g weekly) and easily available to use at nursery, pre-school or school.

Topical corticosteroids

  • The potency of topical corticosteroids should be tailored to the severity of the child's atopic eczema, which may vary according to body site. They should be used as follows:

    • use mild potency for mild atopic eczema

    • use moderate potency for moderate atopic eczema

    • use potent for severe atopic eczema

    • use mild potency for the 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 only (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.

Treatment for infections

  • Children with atopic eczema and their parents or carers should be offered information on how to recognise the symptoms and signs of bacterial infection with staphylococcus and/or streptococcus (weeping, pustules, crusts, atopic eczema failing to respond to therapy, rapidly worsening atopic eczema, fever and malaise). Healthcare professionals should provide clear information on how to access appropriate treatment when a child's atopic eczema becomes infected.

  • Children with atopic eczema and their parents or carers should be offered information on how to recognise eczema herpeticum. Signs of eczema herpeticum are:

    • areas of rapidly worsening, painful eczema

    • clustered blisters consistent with early-stage cold sores

    • punched-out erosions (circular, depressed, ulcerated lesions) usually 1–3 mm that are uniform in appearance (these may coalesce to form larger areas of erosion with crusting)

    • possible fever, lethargy or distress.

Education and adherence to therapy

  • Healthcare professionals should spend time educating children with atopic eczema and their parents or carers about atopic eczema and its treatment. They should provide information in verbal and written forms, with practical demonstrations, and should cover:

    • how much of the treatments to use

    • how often to apply treatments

    • when and how to step treatment up or down

    • how to treat infected atopic eczema.

      This should be reinforced at every consultation, addressing factors that affect adherence.

Indications for referral

  • Referral for specialist dermatological advice is recommended for children with atopic eczema if:

    • the diagnosis is, or has become, uncertain

    • management has not controlled the atopic eczema satisfactorily based on a subjective assessment by the child, parent or carer (for example, the child is having 1–2 weeks of flares per month or is reacting adversely to many emollients)

    • atopic eczema on the face has not responded to appropriate treatment

    • the child or parent/carer may benefit from specialist advice on treatment application (for example, bandaging techniques)

    • contact allergic dermatitis is suspected (for example, persistent atopic eczema or facial, eyelid or hand atopic eczema)

    • the atopic eczema is giving rise to significant social or psychological problems for the child or parent/carer (for example, sleep disturbance, poor school attendance)

    • atopic eczema is associated with severe and recurrent infections, especially deep abscesses or pneumonia.

  • National Institute for Health and Care Excellence (NICE)