Guidelines

Investigation and Diagnosis

Clinical Diagnosis

• Investigations are NOT necessary for establishing diagnosis, but may be useful for excluding differentials

Clinical diagnostic criteria:

• Itchy skin, AND
• ≥3 of the following:
  • Onset <2 y/o (this criterion should not be used in <4 y/o)
  • Visible flexural eczema involving the skin creases (or in ≤18 months: visible eczema on the cheeks and/or extensor areas)
  • Personal history of flexural eczema (or in ≤18 months: history of eczema on the cheeks and/or extensor areas)
  • Personal history of dry skin in the last 12 months.
  • Personal history of asthma or allergic rhinitis (or in <4 y/o: this criterion counts if there is family history of atopic disease in a first-degree relative)

Severity Assessment

The following categorisation is important in guiding management:

Category	Appearance	Psychological impact
Mild	Dry skin Infrequent itching +/- Small areas of redness	Little impact on everyday activities, sleep and psychosocial well-being
Moderate	Dry skin Frequent itching Redness +/- excoriation and skin thickening	Moderate impact on everyday activities, sleep and psychosocial well-being, and frequently disturbed sleep
Severe	Widespread areas of dry skin with: Incessant itching AND/OR Redness +/- excoriation, extensive skin thickening, bleeding, oozing, cracking, alteration of pigmentation	Severe limitations of everyday activities and psychosocial functioning, and loss of sleep every night
Infected	Weeping, or Crusting, or Pustules, or Fever / malaise	n/a

Management

General Self-Care Advice

For all patients, includes:

• Trigger avoidance
• Manage itch & scratching
• Educate on flare-recognition 

Pharmacological Management

Management approach is based on the severity category (see above).

Stepped treatment options for atopic eczema:

Mild eczema	Moderate eczema	Severe eczema
Emollients	Emollients	Emollients
Mild potency topical corticosteroids	Moderate potency topical corticosteroids*	Potent topical corticosteroids*
n/a	Topical calcineurin inhibitors (tacrolimus or pimecrolimus)**	Topical calcineurin inhibitors (tacrolimus or pimecrolimus)**
n/a	Bandages**	Bandages**
n/a	n/a	Phototherapy**
n/a	n/a	Systemic therapy (e.g. oral corticosteroid, cyclosporin, azathioprine)**
* For delicate areas (e.g. face and flexures), start with a corticosteroid that is one potency class lower and only step up if ineffective (i.e. start with mild potency in moderate eczema, and moderate potency in severe eczema).
** Usually only prescribed by a specialist (e.g. GP with a specialist interest in dermatology, a dermatologist, or a paediatrician).

 

The following sections restructure the management of each eczema severity into

• 1) Flare Management
• 2) Maintenance Therapy

Mild Eczema

• Regular emollient use (generous amount to be used 4 times daily on the entire body), even when symptoms are controlled
• Flare: consider mild topical corticosteroid (e.g. hydrocortisone 1%)
  • To be continued for 48 hours after flare is controlled

Active follow-up is rarely required for mild eczema, unless the person or carer requests it

Moderate Eczema

Acute Flare Management

• Moderately potent topical corticosteroid (e.g. betamethasone valerate 0.025% or clobetasone butyrate 0.05%)
  • To be continued for 48 hours after flare is controlled
  • For delicate areas of skin (face and flexures): consider starting with a mild potency topical corticosteroid (e.g. hydrocortisone 1%) and only increase to moderate potency if necessary and aim for maximum of 5 days use
• Continue emollients (but apply at different times from the steroid)
• Consider localised medicated dressings / dry bandages with emollients and topical corticosteroid for 7-14 days
  • Only to be started by a healthcare professional trained in their use

If severe itch / urticaria

• Consider 1-month trial of non-sedating antihistamine (e.g. cetirizine, loratadine, fexofenadine)
• If itching is affecting sleep: consider short course (maximum 2 weeks) of sedating antihistamine (e.g. chlorphenamine)

Maintenance Therapy

• Regular emollient use (generous amount to be used 4 times daily on the entire body), even when symptoms are controlled
• Consider preventive/maintenance treatment
  • 1st line: topical corticosteroid as ‘step down approach‘ or ‘intermittent treatment‘
  • 2nd line: topical calcineurin inhibitors (tacrolimus, pimecrolimus)
    • Only to be prescribed in secondary care
    • Only used in >2 y/o
• Consider localised medicated dressings / dry bandages with emollients to treat areas of chronic lichenified skin

Severe Eczema

Acute Flare Management

• Potent topical corticosteroid (e.g. betamethasone valerate 0.1%)
  • To be continued for 48 hours after flare is controlled
  • For delicate areas of skin (face and flexures): consider starting with a moderate potency topical corticosteroid (e.g. betamethasone valerate 0.025%, clobetasone butyrate 0.05%) aiming for a maximum of 5 days use
• Continue emollients (but apply at different times from the steroid)
• Consider localised medicated dressings / dry bandages with emollients and topical corticosteroid for 7-14 days
  • Only to be started by a healthcare professional trained in their use
• Consider oral corticosteroids (short-course)
  • For severe, extensive eczema causing psychological distress

If severe itch / urticaria

• Consider 1-month trial of non-sedating antihistamine (e.g. cetirizine, loratadine, fexofenadine)
• If itching is affecting sleep: consider short course (maximum 2 weeks) of sedating antihistamine (e.g. chlorpheniramine)

Maintenance Therapy

• Regular emollient use (generous amount to be used 4 times daily on the entire body), even when symptoms are controlled
• Consider preventive/maintenance treatment
  • 1st line: topical corticosteroid as ‘step down approach‘ or ‘intermittent treatment‘
  • 2nd line: topical calcineurin inhibitors (tacrolimus, pimecrolimus)
    • Only to be prescribed by secondary care
    • Only used in >2 y/o
• Consider localised medicated dressings / dry bandages with emollients to treat areas of chronic lichenified skin

Further Secondary Care Therapy

If above interventions have failed, consider:

• Phototherapy
• Systemic immunosuppressants (e.g. cyclosporin, azathioprine)

Infected Eczema

Admission to hospital indicated if eczema herpeticum is suspected

DO NOT routinely offer topical / oral antibiotic for secondary bacterial infection of eczema, unless systemically unwell:

• If antibiotic is offered, 1st line: flucloxacillin (alternative: clarithromycin)
• For localised infection: consider topical fusidic acid

Episodes of infected eczema usually co-exist with a flare and will require concomitant treatment as described above.

References

Original Guideline