Dr Jamal Karwan MB ChB PLAB DipAD MRCGP (Lon) MRCP (UK) is a General Practitioner at Bupa Cromwell Hospital.
Atopic eczema (atopic dermatitis) is a chronic, relapsing, inflammatory skin condition characterised by an itchy red rash that favours skin creases such as the folds of the elbows or behind the knees. Atopic eczema often has a genetic component that leads to the breakdown of the skin barrier. This makes the skin susceptible to trigger factors, including irritants and allergens, which can make the eczema worse.
It is a common condition and the prevalence is increasing. Eczema affects 15-20% of school aged children and the majority (about 80%) of cases present before the age of five years.
Many cases of atopic eczema clear up or improve during childhood, but others persist into adulthood. Some children with atopic eczema will go on to develop asthma and/or allergic rhinitis; a sequence of events that is sometimes referred to as the ‘atopic march’.
An itchy skin condition (or report of scratching or rubbing in a child) plus three or more of the following:
- History of itchiness of flexor surfaces or around the neck (or itchiness of the cheeks in children <4 years).
- History of asthma or hay fever (or history of atopic disease in a first-degree relative in children <4 years).
- General dry skin in the past year.
- Visible flexural eczema (or eczema affecting the cheeks or forehead and outer limbs in children <4 years).
- Onset in the first two years of life (not always diagnostic in children aged under 4 years).
- Irritants - soaps and detergents (including shampoos, bubble baths and shower gels).
- Skin infections.
- Contact allergens.
- Dietary factors.
- Inhaled allergens, e.g. house dust mites, pollens, pet dander and moulds.
- Investigations are rarely required to establish the diagnosis.
- Most children with mild atopic eczema do not need clinical testing for allergies. Estimation of immunoglobulin E (IgE) and specific radioallergosorbant tests (RASTs) only confirm the atopic nature of the individual.
- Swabs for bacteriology are useful if patients do not respond to treatment, in order to identify antibioticresistant strains of Staphylococcus aureus or to detect additional streptococcal infection.
NICE clinical guidance on atopic eczema in children recommends a stepped approach to management, which means tailoring the treatment step to the severity of the atopic eczema. Emollients should form the basis of 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.
- Provide information about the condition, the factors that may provoke it, the role of different treatments and their effective, safe use. It is important to emphasise the correct quantities of topical treatments to use. Provide written information to reinforce discussion.
- Include information on how to recognise flares of atopic eczema (increased dryness, itching, redness, swelling and general irritability).
- Provide information on recognising the symptoms and signs of bacterial infection (weeping, crusting or pustules, rapidly worsening atopic eczema, failing to respond to therapy, fever and malaise).
- Provoking factors should be identified and avoided when practical.
- Keep the skin hydrated.
Emollients are the mainstay of therapy and essential to manage eczema effectively. They should be applied as liberally and frequently as possible and continual treatment with complete emollient therapy (combinations of cream, ointment, bath oil and emollient soap substitute) will help to provide maximal effect.
Leave-on emollients should be prescribed in large quantities (250–500g weekly) and made easily available to use at nursery, pre-school or school. Ointments (such as Epaderm) are preferable for dry skin or at night, whilst creams (such as Diprobase) are preferable for inflamed areas for use during the day.
Patients getting frequent flares may benefit from emollients with an antiseptic property (e.g. Dermol ® 600 Bath Emollient or Dermol 200 ® Shower Emollient), whilst those with very itchy skin may benefit from an emollient with an antipruritic property (such asBalneum-plus ® Bath Oil).
The intensive use of emollients will reduce the need for topical steroids, but when these are required they should be used at the lowest appropriate potency and only applied thinly to inflamed skin. The strength of steroid is determined by the age of the patient and the site and severity of eczema; for example mild potency if on a child’s face (e.g. 1% hydrocortisone), and moderate potency for a child’s trunk or limbs (e.g. Eumovate ® - clobetasone butyrate 0.05%). Moisturisers should be given twenty minutes to dry into skin before the steroid is applied.
The use of topical antibiotics, including those combined with topical corticosteroids, should be reserved for cases of clinical infection in localised areas and used for no longer than two weeks.
Systemic antibiotics that are active against Staphylococcus aureus and streptococcus should be used to treat widespread bacterial infections of atopic eczema in children for 1–2 weeks according to clinical response. Using combined steroid / antibiotic preparations (e.g. Fucibet and Fucidin-H cream) on a regular basis should be avoided as this will increase the risk of antibiotic resistance.
Treatment with immunomodulators
Topical pimecrolimus and tacrolimus are options for atopic eczema not controlled by maximal topical corticosteroid treatment, or if there is a risk of important corticosteroid side-effects (particularly skin atrophy).
NICE has recommended that treatment with tacrolimus or pimecrolimus be initiated only by physicians with a special interest and experience in dermatology, and only after careful discussion with the patient about the potential risks and benefits of all appropriate second-line treatment options.
When to refer to a specialist
- Immediate (same day) referral for specialist dermatological advice if eczema herpeticum is suspected. This would be suggested by the appearance of clusters of vesicles in an area of rapidly worsening, painful eczema.
- Urgent (within two weeks) referral if the atopic eczema is severe and has not responded to optimum topical therapy after one week, or treatment of bacterially infected atopic eczema has failed.
- Routine referral if:
- The diagnosis is uncertain.
- Management has not controlled the atopic eczema satisfactorily.
- The child or parent / carer may benefit from specialist advice on treatment application such as bandaging techniques.
- Atopic eczema on the face has not responded to appropriate treatment.
- Contact allergic dermatitis is suspected (e.g. 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 (sleep disturbance, poor school attendance).
- Atopic eczema is associated with severe and recurring infections, especially deep abscess or pneumonia.
Eczema and allergy
Food allergy has a role in 7% of atopic eczema cases. It predominantly affects children under the age of three, and should be considered in this age group if associated with a perioral flare when eating. Also if moderate to severe eczema is responding poorly to appropriate treatment, or when there are co-existing GI symptoms. Reflux, vomiting, colic, diarrhoea and food refusal can all be associated with cow’s milk protein allergy (CMPA), as can wheezing and failure to thrive.
For bottle fed infants aged under six months with moderateor severe atopic eczema that has not been controlled with emollients and mild topical corticosteroids, NICE recommends an alternative to cow’s milk formula. The recommendation is for a 6–8 week trial of an extensively hydrolysed protein formula (e.g.Nutramigen or Cow & Gate Pepti) or amino acid formula (such as Neocate).
GPs should consider a diagnosis of inhalant allergy in children with seasonal flares of atopic eczema, children with atopic eczema associated with asthma or allergic rhinitis, and children aged three years or over with atopic eczema on the face, particularly around the eyes.
Stepped approach to management