Eczema

Key NICE recommendations on management

Use a stepped-care approach for atopic eczema, adjusting treatment according to symptom severity. Consider that atopic eczema of any severity can negatively impact quality of life.

• Assess severity across all areas of atopic eczema. If there are areas of differing severity, treat each area independently.

• See the NICE guideline for more information on use of the stepped-care approach and the treatments described in this summary (including cautions and directions for use, and patient advice/education [including on how/when to use treatments]).

Start treatment for atopic eczema flares as soon as signs and symptoms (e.g., increased dryness, redness, itching, swelling and general irritability) appear. Continue treatment for approximately 48 hours after symptoms subside.

• Advise avoidance of potential flare triggers (e.g., stress, humidity) where possible.

If eczema herpeticum (widespread herpes simplex infection) is suspected, immediately start systemic aciclovir and refer for same-day specialist dermatological advice.

• If skin around the eyes is involved, also refer for same-day ophthalmological advice.

• If secondary bacterial infection is also suspected, start systemic antibiotics.

• See the NICE guideline for more information on managing infections in children with atopic eczema.

Emollients

Emollients are the basis of management and should always be used, even when atopic eczema is clear. Offer a choice of unperfumed emollients for everyday moisturising and prescribe large quantities of leave-on emollients.

• If the current emollient causes irritation or is not acceptable, offer a different way to apply it or an alternative emollient. Review repeat prescriptions at least annually.

• Emollient creams are vital in managing atopic eczema, but note MHRA warnings about fire hazards associated with emollient residue build-up on clothing/bedding.

Offer personalised advice on washing with emollients or emollient soap substitutes instead of soaps, detergent-based wash products, and - in children under 12 months - shampoos.

• Do not offer emollient bath additives (leave-on emollients can be added to a bath).

Topical corticosteroids

Tailor the potency of topical corticosteroids to the site and severity of atopic eczema. In general, use mild potency for mild atopic eczema, moderate potency for moderate atopic eczema, and potent for severe atopic eczema. The following are exceptions:

• Use mild potency for face and neck, except for short-term (3 to 5 days) use of moderate potency for severe flares. Do not use potent preparations on face or neck

• Use moderate or potent preparations for short periods only (7 to 14 days) for flares in vulnerable sites such as axillae and groin

• Do not use potent preparations in children under 12 months, or very potent preparations in children of any age, without specialist dermatological advice.

Topical corticosteroids should be prescribed for application only once or twice daily. They should only be applied to areas of active or recently active (within past 48 hours) eczema.

If a mild or moderate potency topical corticosteroid has not controlled the atopic eczema within 7 to 14 days:

• Exclude secondary bacterial or viral infection

• For children aged 12 months or over, use potent preparations for as short a time as possible (no longer than 14 days, and not on the face or neck)

• If still uncontrolled, review the diagnosis and refer for dermatological advice.

Once atopic eczema is controlled, consider treating problem areas with topical corticosteroids for 2 consecutive days per week to prevent flares in children with frequent flares (2 or 3 per month). Review this strategy within 3 to 6 months.

If tachyphylaxis to a topical corticosteroid is suspected, consider a different topical corticosteroid of the same potency as an alternative to stepping up treatment.

Topical calcineurin inhibitors

Topical calcineurin inhibitors (e.g., tacrolimus, pimecrolimus) should only be initiated by physicians with special dermatology interest and experience after careful discussion with the patient about potential risks/benefits of all appropriate second-line treatment options.

Topical calcineurin inhibitors should be considered:

• As second-line treatment options for moderate to severe atopic eczema that has not responded satisfactorily to adequate topical corticosteroids and where further use of these poses a serious risk of important adverse effects (particularly irreversible skin atrophy)

• As a step up in treatment for facial atopic eczema that requires long-term or frequent use of mild topical corticosteroids.

Do not use topical calcineurin inhibitors:

• For mild atopic eczema

• As first-line treatment for atopic eczema of any severity

• Under occlusion (bandages, dressings) without specialist dermatological advice.

Bandages and other treatments

Dry bandages and medicated dressings (including wet wrap therapy) are options for moderate or severe atopic eczema. Consider using localised medicated dressings or dry bandages with:

• Emollients as a treatment for areas of chronic lichenified (localised skin thickening) atopic eczema

• Emollients and topical corticosteroids for short-term treatment of flares (7 to 14 days) or areas of chronic lichenified atopic eczema.

Do not use:

• Occlusive medicated dressings and dry bandages to treat infected atopic eczema

• Whole-body (limbs and trunk) occlusive dressings or dry bandages as first-line treatment. These should be started by a healthcare professional trained in their use.

Phototherapy or systemic treatments are options for severe atopic eczema when other treatments have failed/are inappropriate, and there is a significant negative impact on quality of life. These treatments should only be used under specialist dermatological supervision.

Do not routinely use oral antihistamines to manage atopic eczema in children. Offer:

• A 1-month trial of a non-sedating antihistamine, for severe atopic eczema or for mild or moderate atopic eczema associated with severe itching or urticaria. If successful, consider continuing while symptoms persist, and review every 3 months

• A 7 to 14-day trial of an age-appropriate sedating antihistamine to children aged 6 months or over during an acute flare, if sleep disturbance has a significant impact on the child or parents/carers. Consider repeating this during subsequent flares.

Refer children with moderate or severe atopic eczema and suspected food allergy for specialist investigation and management.

• See the NICE guideline for information on dietary management in selected children.

Advise caution around use of herbal medicines, and ask that any use of these or other complementary therapies (e.g., food supplements, homeopathy) be discussed with the child's healthcare team.

Indications for referral

Refer children for specialist dermatological advice:

• Urgently (within 2 weeks) if atopic eczema is severe and has not responded to optimal topical therapy after 1 week, or if treatment of bacterially infected atopic eczema has failed

• If the diagnosis of atopic eczema is, or has become, uncertain

• If allergic contact dermatitis is suspected

• If management has not controlled atopic eczema satisfactorily, or if facial atopic eczema has not responded to treatment

• If they may benefit from specialist treatment application advice (e.g., for bandaging)

• If atopic eczema is causing significant psychosocial problems for the child or their parents/carers (e.g., sleep disturbance, poor school attendance)

  • Refer for psychological advice if atopic eczema is responding to optimal management but quality of life/psychosocial wellbeing has not improved

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

Refer children for specialist growth advice if not growing as expected (on UK growth charts).

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