Quality statement 2: Stepped approach to management

Quality statement

Children with atopic eczema are offered treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Rationale

Atopic eczema is typically an episodic condition consisting of flares and remissions, though in some children it is continuous. Treatment for atopic eczema should be tailored, with treatments stepped up and down according to the recorded severity of symptoms. Areas of atopic eczema of differing severity can coexist in the same child, and each area should be treated independently. The stepped-care plan involves self-management and adherence to treatment, therefore healthcare practitioners should give children with atopic eczema and their families or carers support and information on when and how to step treatment up or down.

Quality measures

Structure

Evidence of local arrangements to ensure that children with atopic eczema are offered treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Data source: Local data collection.

Process

a) The proportion of children with atopic eczema who have their eczema severity recorded at each eczema consultation.

Numerator – the number of children in the denominator who have their eczema severity recorded at each eczema consultation.

Denominator – the number of eczema consultations with children with atopic eczema.

Data source: Local data collection.

b) The proportion of children with atopic eczema who receive treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Numerator – the number of children in the denominator who receive treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Denominator – the number of children with atopic eczema.

Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place to offer children with atopic eczema treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Healthcare practitioners offer children with atopic eczema treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Commissioners ensure that they commission services with local arrangements to offer children with atopic eczema treatment based on recorded eczema severity using the stepped-care plan, supported by education.

What the quality statement means for patients and carers

Children with atopic eczema are offered treatment using a stepped-care plan (which means that treatments are added or stopped depending on how severe the eczema is) and given advice and information about atopic eczema and its treatment.

Source guidance

Definitions of terms used in this quality statement

Eczema severity

NICE clinical guideline 57 recommends an assessment of the physical severity of atopic eczema and the impact of atopic eczema on quality of life and social wellbeing at each eczema consultation. The guideline defines the physical severity of atopic eczema as follows:

  • Clear: normal skin, no evidence of active atopic eczema

  • Mild: areas of dry skin, infrequent itching (with or without small areas of redness)

  • Moderate: areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening)

  • Severe: widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation).

Stepped approach to management

NICE clinical guideline 57 recommends that healthcare practitioners use a stepped approach to managing atopic eczema in children, which 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, by adding or withdrawing treatments as follows (phototherapy and systemic therapy should be undertaken only under specialist dermatological supervision by staff who are experienced in dealing with children):

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 practitioners should review repeat prescriptions of individual products and combinations of products with children with atopic eczema (and their parents or carers) at least once a year to ensure that treatment remains optimal.

Supported by education

Education on the use of, and adherence to, treatment is essential to the stepped-care plan approach. NICE clinical guideline 57 recommends that healthcare practitioners offer children with atopic eczema (and their parents or carers) information on how to recognise the symptoms and signs of bacterial infection and also how to recognise and manage flares of atopic eczema according to the stepped-care plan. Healthcare practitioners 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 to apply and how often to apply prescribed treatments, including emollients, steroids, calcineurin inhibitors and medicated dressings (bandages)

  • 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.

Equality and diversity considerations

Healthcare practitioners should be aware of the potential difficulties of assessing eczema severity in children with darker skin tones.

In recommending skin treatments, healthcare practitioners should be sensitive to the cultural practices of families or carers of children with atopic eczema. For example, if families or carers use olive oil as a skin treatment (which is likely to be harmful to a child's skin) or if they rinse children after bathing (rinsing off emollients), the reasons for using the recommended treatment and applying it correctly should be explained sensitively.