Atopic eczema

Mild: Localised areas of dry skin, infrequent itching (with or without small areas of redness or altered pigmentation). Little impact on everyday activities, sleep and psychosocial wellbeing. 

• Prescribe generous amounts of emollients (patient’s preference); advise frequent, liberal, daily use.  
• Prescribe a mild topical corticosteroid (e.g. hydrocortisone 1%) for areas of red skin or altered pigmentation. Continue treatment for 48 hours after flare is controlled. 
• Consider prescribing a one-month trial of non-sedating antihistamines only in cases of severe itch or urticaria. Review every three months if suitable. 
• Do not routinely take a skin swab for microbiological testing in people with secondary bacterial infection of eczema at the initial presentation; In people who are not systemically unwell, do not routinely offer either a topical or oral antibiotic for secondary bacterial infection of eczema. 

Moderate: Localised areas of dry skin, frequent itching, redness or altered pigmentation in skin of colour (with or without excoriation and localised skin thickening). Moderate impact on everyday activities and psychosocial wellbeing, frequently disturbed sleep. 

• Prescribe generous amounts of emollients (patient’s preference); advise frequent, liberal, daily use. 
• Prescribe a moderately potent topical corticosteroid if skin is inflamed (e.g. betamethasone valerate 0.025%, clobetasone butyrate 0.05%). Continue treatment for 48 hours after flare is controlled.  
• Prescribe a mild potency topical corticosteroid for delicate face/flexural skin areas (e.g. hydrocortisone 1%); increase to moderate potency corticosteroid if necessary. Continue treatment for maximum of 5 days. 
• Prescribe topical calcineurin inhibitors for facial eczema unresponsive to moderate topical corticosteroids e.g. Tacrolimus (0.03% if aged 2-12; 0.1% b.d. if aged over 12) or pimecrolimus. 

For frequent flares consider:  

• A step-down treatment using lower potency corticosteroid (typically a class down from what is used for flare) 
• Intermittent treatment on two consecutive days of the week (weekend) or twice-weekly (e.g. every 3-4 days).  

Severe: Widespread areas of dry skin, incessant itching, redness or altered pigmentation in skin of colour (with or without excoriation, extensive skin thickening, bleeding, oozing and cracking). Severe limitation of everyday activities and psychosocial functioning, nightly loss of sleep. 

• Prescribe generous amounts of emollients (patient’s preference); advise frequent, liberal, daily use.  
• Prescribe a potent topical corticosteroid for inflamed areas, e.g. betamethasone valerate 0.1% or mometasone 0.1%, on the body. Continue treatment for 48 hours after flare is controlled.  

Oral corticosteroids should be reserved for use in the treatment of severe flares, often while waiting for referral to secondary care  

Secondary infection 

• Prescribe systemic antibiotics if patients are systemically unwell with suspected secondary bacterial infection.  
• For people with secondary bacterial infection of eczema that is worsening or has not improved, consider sending a skin swab for microbiological testing. (flucloxacillin 1st line; erythromycin if penicillin allergic or resistance to flucloxacillin). 
• Eczema herpeticum - Prescribe systemic aciclovir and refer patient as medical emergency if eczema herpeticum (widespread herpes simplex virus) is suspected with atopic eczema (sudden onset of painful, uniform grouped vesicles/erosions). 

• Manage mild in primary care, do not refer.  
• Manage moderate in secondary care service if multiple treatments in primary care have failed, or if patient’s mental health is being adversely affected by their eczema. 
• Refer to secondary/tertiary care if the atopic eczema is severe and has not responded to optimum topical therapy (potent corticosteroids on the body). 
• Refer as an emergency if eczema herpeticum is suspected, and in cases of erythroderma (>70-90% of body surface area). 

Clinical assessment tools  EASI,  SCORAD,  Quality of life assessment – DLQI, POEM 

Clinical knowledge summaries:  

BNF corticosteroids (and finger unit measurement) 

NICE CKS- Prescribing Corticosteroids 

NICE Secondary bacterial infection of NICE CKS- Atopic Eczema eczema and other common skin conditions: antimicrobial prescribing;  

PCDS Treatment Guide- Atopic Eczema, DermNet NZ- Atopic Dermatitis: BAD Skin Diversity Descriptors   

• The diagnosis is unlikely to be atopic eczema if there is no itch. 
• Suspect food allergy in children who have reacted previously to food with immediate symptoms, or in infants and young children with moderate to severe eczema not responding to optimum management, particularly if associated with gastrointestinal symptoms. 
• Long-term use of appropriate emollient therapy is important. Patients with generalised eczema require up to 500g per week of emollient. Applying emollients from the fridge can help with itch. Avoid aqueous cream as a leave-on emollient, due to high risk of skin irritation. 
• Consider allergic contact dermatitis if condition not improving, and the given treatment is felt to be causing a further reaction.  
• Consider allergic contact eczema when there is a change in pattern of eczema – e.g. hand and face eczema 
• Occlusive dressings such as wet wraps (YouTube video: How to apply wet wraps) or dry bandages can help penetration of corticosteroid and can help break the itch-scratch cycle (should be avoided when infected). Beware the risk of atrophy with prolonged occlusion. 
• Topical calcineurin inhibitors are useful second-line agents, particularly for facial eczema. They can be used intermittently for maintenance. Initial stinging often occurs but tends to improve with continued use. Avoid in infected eczema. 
• With recurrent infected eczema, consider swabbing the nose of patients and family members to look for staphylococcus aureus carriage to help guide decolonisation regimens. 

British Association of Dermatologists: Atopic eczema

Patient.info: Atopic eczema: see also Patient.info: Fingertip Units for Topical Steroids

British Association of Dermatologists Atopic eczema

Inflammatory 

ICD11 code - EA80