Dr Caroline Ward discusses NICE recommendations on the treatment of atopic eczema, focusing on eczema complicated by bacterial or viral infection

Read this article to learn more about:

Photograph of Dr Caroline Ward

Dr Caroline Ward

  • stepped treatment options for the management of atopic eczema
  • when to prescribe antibiotics, and antibiotic choice in children and adults
  • red flags for referral or hospital admission.

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Atopic eczema is a chronic, itchy, inflammatory skin condition characterised by flares and remissions; however, in severe eczema, symptoms may be continuous.1 Although atopic eczema can affect people of all ages, it presents most frequently in children, with 70–90% of cases occurring before 5 years of age.1 The condition resolves in about 65% of children by 7 years of age, and in about 74% of children by 16 years of age.2

A ’stepped approach’ is recommended by NICE for the management of eczema, with treatment stepped up or down according to the current severity of the condition.1,3 NICE categorises eczema as mild, moderate, or severe (see Box 1).4,5

Box 1: Classification of the severity of eczema4,5

  • 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).

© NICE 2021. Atopic eczema in under 12s: diagnosis and management. Available from: www.nice.org.uk/cg57

© NICE 2021. Eczema—atopic: scenario, assessment. cks.nice.org.uk/topics/eczema-atopic/management/assessment/

All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

Management of atopic eczema

Topical emollients are the mainstay of treatment for all patients with eczema; they should be used liberally and regularly, even when skin is clear, and their use should be increased during a flare.6 Patients with eczema should be advised to treat areas of eczema with unperfumed emollients to avoid skin reactions associated with additives in some emollients; they should also avoid the use of soaps, instead using a soap substitute such as an emollient for washing.6

Topical corticosteroids should usually be used once or twice a day for flares of eczema, and continued for 48 hours after the flare has been controlled.7 Topical corticosteroids are available in four potencies: mildly potent, moderately potent, potent, and very potent. The potency prescribed should be tailored to the severity of symptoms and area of the body involved.7 The face, genitals, and flexures are considered delicate areas of skin; thus, mild-potency steroids should usually be tried first line in these areas, aiming for a maximum duration of 5 days’ use.7 Very potent preparations are usually only used under specialist dermatological advice, especially in children.7

Table 1 shows the stepped approach advocated by NICE for mild, moderate, and severe eczema, and Table 2 shows the topical corticosteroids that are available for each of the four potencies.3,7,8

Table 1: Stepped treatment options for atopic eczema3,8
Mild atopic eczemaModerate eczema[A]Severe eczema
Emollients Emollients Emollients
Mild potency topical corticosteroids Moderate potency topical corticosteroids Potent topical corticosteroids
Topical calcineurin inhibitors (tacrolimus or pimecrolimus)[B] Topical calcineurin inhibitors (tacrolimus or pimecrolimus)[B]
Bandages[B] Bandages[B]
Phototherapy[C]
Oral corticosteroids[D]

[A] If there is severe itch or urticartia, consider prescribing a one-month trial of a non-sedating antihistamine (such as cetirizine, loratadine, or fexofenadine. Review the use of non-sedating antihistamines every 3 months (treatment can be stopped, then restarted if symptoms worsen).8

[B] Usually only prescribed by a specialist (for example, a GP with a specialist interest in dermatology, a dermatologist, or a paediatrician).

[C] Phototherapy is available in secondary care for the treatment of very severe eczema that has proved resistant to standard treatment. Systemic immunosuppressants (for example, ciclosporin and azathioprine) are also available in secondary care for the same indication.

[D] Oral corticosteroids can be prescribed short-term in primary care for severe flares. Other systemic treatments suitable for maintenance of severe eczema (for example, ciclosporin or azathioprine) require referral to secondary care.

© NICE 2021. Eczema—atopic: NICE stepped approach to treatmentcks.nice.org.uk/topics/eczema-atopic/prescribing-information/stepped-approach-to-treatment/ All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.
Table 2: Examples of topical corticosteroids of different potencies7,[A]
PotencyTopical corticosteroid

Mildly potent

Hydrocortisone 0.1%, 0.5%, 1.0%, and 2.5%[B]

Moderately potent

Betamethasone valerate 0.025% (Betnovate-RD®)

Clobetasone butyrate 0.05% (Eumovate®)

Potent

Betamethasone valerate 0.1% (Betnovate®)

Betamethasone dipropionate 0.05% (Diprosone®)

Very potent[C]

Clobetasol propionate 0.05% (Dermovate®)

Diflucortolone valerate 0.3% (Nerisone Forte®)

[A] See the British National Formulary (bnf.nice.org.uk) for a complete list of all topical corticosteroids available in the UK.

[B] Hydrocortisone 1% is available over the counter for mild-to-moderate eczema not involving the face or genitals.

[C] Very potent topical corticosteroids should usually only be prescribed by specialists.

© NICE 2021. Eczema—atopic: topical corticosteroids. cks.nice.org.uk/topics/eczema-atopic/prescribing-information/topical-corticosteroids/ All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

Mild eczema

Regarding the treatment of mild eczema, NICE recommends prescribing a mild topical corticosteroid for areas of red skin. Active follow up is rarely required for mild eczema.9

Moderate eczema

A moderately potent topical corticosteroid can be used for the treatment of moderate eczema if skin is inflamed, although on delicate areas of skin it may be more appropriate to start with a mild-potency corticosteroid.8 In patients with severe itch or urticaria, a 1-month trial of a non-sedating antihistamine (for example, cetirizine, loratadine, or fexofenadine) may be of benefit.8

Consider the need for referral to dermatology if skin is not responding as expected, or hospital admission if there are signs and symptoms of eczema herpeticum.8

Severe eczema

For the management of severe eczema, a potent topical corticosteroid should be used on inflamed areas. For delicate areas of skin, use a moderate-potency corticosteroid, and aim for a maximum of 5 days’ use.10

Severe itch or urticaria may be managed with a 1-month trial of a non-sedating antihistamine. If itching is interrupting sleep, a short course (maximum 2 weeks) of a sedating antihistamine (for example, chlorphenamine) can be prescribed.10

In adults with severe, extensive eczema causing psychological distress, a short course of an oral corticosteroid such as 30 mg prednisolone for 7 days may be beneficial.10 However, there are no data from controlled trials on the use of oral corticosteroids in this scenario, and NICE recommends referral for children aged under 16 years with severe, extensive eczema causing psychological distress.10

Patients with severe eczema should be referred for a routine dermatology appointment if:10

  • the diagnosis is, or has become, uncertain
  • current management has not controlled eczema satisfactorily
  • facial eczema has not responded to treatment
  • treatment application advice is needed
  • contact allergic dermatitis is suspected
  • there is recurrent secondary infection
  • eczema is causing significant social or psychological problems.

Admit to hospital if eczema herpeticum (Figure 1) is suspected.10

eczema-herpeticum-00008 resized

Figure 1: Eczema herpeticum

© DermNet New Zealand. Reproduced with permission.

Management of infection

Eczema can be complicated by either viral or bacterial infection. Superficial fungal infections are also more common in people with eczema than in those without.1

Eczema herpeticum

Eczema herpeticum is caused by widespread infection with the herpes simplex (cold sore) virus, and is considered a medical emergency.4,11,12 Disseminated eczema herpeticum presents with areas of painful, worsening eczema and small clustered uniform blisters, which may coalesce and lead to extensive lesions and large areas of desquamation and bleeding (see Figure 1).12 In its more localised form, herpes simplex infection typically presents with grouped vesicles, but punched-out erosions may also occur.4,13 A diagnosis of eczema herpeticum should be considered if infected eczema fails to respond to treatment with antibiotics and an appropriate topical corticosteroid.4,11

If eczema herpeticum is suspected, treatment with oral aciclovir should be started; in addition, NICE advises that children with suspected eczema herpeticum are referred for same-day specialist dermatological advice.14 Children with eczema herpeticum are often systemically unwell with fever, lymphadenopathy, and malaise, and require urgent referral to hospital.12,13

Bacterial infection

Eczema is often colonised with bacteria, but may not be clinically infected.11 Infection is commonly caused by Staphylococcus aureus, and may present as rapidly worsening eczema or failure to respond to treatment.11 There may also be weeping, pustules, crusts, fever, and malaise.11 However, not all eczema flares are caused by a bacterial infection, even if weeping and crusts are present, and flares not caused by bacterial infection will not respond to antibiotics.11 Evidence shows a limited benefit of antibiotics even when typical signs and symptoms of infection are present.11

Use of antibiotics

Given that—even when typical signs and symptoms of infection are present (for example, crusting, weeping, or pustules)—the evidence shows limited benefits of antibiotics in addition to usual care with emollients and topical steroids, antibiotics should not be routinely offered to patients who are systemically well.11 Antibiotics should only be used when the infection is severe, the patient is systemically unwell with fever and/or malaise, or they are at increased risk of complications (for example, people who are immunosuppressed).11

The treatment options for infected eczema are presented in Tables 3 and 4.11

Table 3: Choice of antibiotics for adults aged 18 years and over11
TreatmentAntibiotic, dosage and course length 
For secondary bacterial infection of eczema in people who are not systemically unwell Do not routinely offer either a topical or oral antibiotic
First choice topical if a topical antibiotic is appropriate

Fusidic acid 2%:

Apply three times a day for 5 to 7 days

For localised infections only. Extended or recurrent use may increase the risk of developing antimicrobial resistance

First choice oral if an oral antibiotic is appropriate

Flucloxacillin:

500 mg four times a day for 5 to 7 days

Alternative oral antibiotic if the person has a penicillin allergy or flucloxacillin is unsuitable

Clarithromycin:

250 mg twice a day for 5 to 7 days

The dosage can be increased to 500 mg twice a day for severe infections

Alternative oral antibiotic if the person has a penicillin allergy or flucloxacillin is unsuitable, and the person is pregnant

Erythromycin:

250 mg to 500 mg four times a day for 5 to 7 days

If methicillin-resistant Staphylococcus aureus is suspected or confirmed Consult a microbiologist
© NICE 2021. Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribingwww.nice.org.uk/ng190 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.
Table 4: Choice of antibiotics for children and young people aged from 1 month to under 18 years11
Treatment Antibiotic, dosage and course length 
For secondary bacterial infection of eczema in people who are not systemically unwell Do not routinely offer either a topical or oral antibiotic
First choice topical if a topical antibiotic is appropriate

Fusidic acid 2%:

Apply three times a day for 5 to 7 days

For localised infections only. Extended or recurrent use may increase the risk of developing antimicrobial resistance

First choice oral if an oral antibiotic is appropriate

Flucloxacillin (oral solution or capsules):

1 month to 1 year: 62.5 mg to 125 mg four times a day for 5 to 7 days

2 years to 9 years: 125 mg to 250 mg four times a day for 5 to 7 days

10 years to 17 years: 250 mg to 500 mg four times a day for 5 to 7 days

Alternative oral antibiotic if the person has a penicillin allergy or flucloxacillin is unsuitable

Clarithromycin:

1 month to 11 years:

  • under 8 kg: 7.5 mg/kg twice a day for 5 to 7 days
  • 8 kg to 11 kg: 62.5 mg twice a day for 5 to 7 days
  • 12 kg to 19 kg: 125 mg twice a day for 5 to 7 days
  • 20 kg to 29 kg: 187.5 mg twice a day for 5 to 7 days
  • 30 kg to 40 kg: 250 mg twice a day for 5 to 7 days

12 years to 17 years:

  • 250 mg twice a day for 5 to 7 days. The dosage can be increased to 500 mg twice a day for severe infections
Alternative oral antibiotic if the person has a penicillin allergy or flucloxacillin is unsuitable, and the person is pregnant

Erythromycin:

8 years to 17 years: 250 mg to 500 mg four times a day for 5 to 7 days

If methicillin-resistant Staphylococcus aureus is suspected or confirmed  Consult a local microbiologist
© NICE 2021. Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribingwww.nice.org.uk/ng190 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

The following points should be noted and discussed with patients/carers when considering initiation of antibiotic treatment:11

  • the evidence, which suggests limited benefits of antibiotics
  • the risk of antimicrobial resistance with repeated courses of antibiotics
  • possible side-effects.

Whether or not an antibiotic is given, advise the patient to continue with regular treatments such as emollients and topical steroids, and to seek medical help if symptoms worsen rapidly or significantly at any time.11

Choosing between oral and topical antibiotics

A topical antibiotic is usually more appropriate than an oral antibiotic if the person is not systemically unwell, and if the infection is localised and not severe.11 Fusidic acid 2% should be prescribed as the first-line topical antibiotic. Other topical treatments, such as mupirocin, should be reserved for specific indications such as methicillin-resistant Staphylococcus aureus (MRSA) decolonisation.11 If fusidic acid is unsuitable or ineffective, an oral antibiotic would be a more suitable choice.11

An oral antibiotic rather than a topical antibiotic is more appropriate if the person is systemically unwell, or if the infection is widespread or severe.11

Some children may not tolerate flucloxacillin solution because of its unpleasant taste, in which case tablets or capsules can be considered. There are some useful resources available for parents to encourage children to swallow tablets or capsules (for example, the Medicines for Children leaflet Helping your child to swallow tablets, available at: bit.ly/3wAQWFG). For children who are unable to swallow capsules, one of the alternative oral antibiotics would be suitable.11

Course length and dosage

To reduce the risk of antimicrobial resistance and adverse effects, the shortest course of an antibiotic that is likely to be effective should be prescribed.11 Five to 7 days of treatment should be sufficient to treat secondary bacterial infection of eczema.11 In the past, NICE recommended the use of fusidic acid 2% for 1–2 weeks; however, a shorter duration of 5–7 days is now recommended in order to provide effective treatment while reducing the risk of resistance.11

Microbiological testing

A skin swab is not routinely recommended at the initial presentation of infected eczema.11 Eczema is often colonised with bacteria, and may not be clinically infected. Therefore, there is a possibility of culturing and identifying colonising rather than infective bacteria, and subsequent initiation of inappropriate or unnecessary antibiotics.11

A skin swab should be considered if:11

  • infection is worsening or has not improved as expected after first-line antibiotic treatment
  • a patient has frequent recurrences of infected eczema. This may help to guide future antibiotic choice if the person has a resistant infection. In this instance, you should also consider taking a nasal swab to check for Staphylococcus aureus, which may indicate MRSA carriage; if found, start treatment for decolonisation as per local guidelines or microbiology advice.

If a skin swab has been sent off for microbiological testing, the results should be reviewed when available and the antibiotic changed according to the results if symptoms are not improving, using a narrow-spectrum antibiotic if possible.11

Referral and seeking specialist advice

Patients should be referred to hospital if they have any signs or symptoms suggestive of a more serious illness or condition, such as sepsis, or necrotising fasciitis.11

Consider referral or specialist advice for patients with infected eczema if they have spreading infection that is not responding to oral antibiotics, are systemically unwell, are at high risk of complications, or have infections that recur frequently.11

Reassessment

Patients should be advised to return for reassessment if they become systemically unwell, develop severe pain, or their symptoms have not improved after a complete course of antibiotics.11

If patients do present for reassessment, consider other possible diagnoses, such as viral infection (for example, eczema herpeticum), more serious conditions (such as cellulitis, necrotising fasciitis, or sepsis), or treatment failure due to the development of resistant bacteria as a result of previous antibiotic use.11

Summary

The mainstay of treatment for all severities of eczema should be liberal and frequent use of topical emollients, even when skin is clear, and to be continued during flares. Additional treatments, such as topical steroids, should be tailored to the severity of the presenting symptoms and signs, then treatment stepped down once symptoms improve. Evidence shows a limited benefit of antibiotic use even when typical symptoms and signs of infection are present. Therefore, antibiotics should usually be reserved for those who are systemically unwell, at increased risk of complications, or with severe infection.

Dr Caroline Ward

GP and standing member of the NICE Managing Common Infections Advisory Committee

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you to consider how to deliver improvements to healthcare within the available resources.

  • Review local care pathways for the management of eczema
  • Update local formularies with choices of emollients and other topical preparations for eczema treatment
  • Consider publishing information leaflets explaining the correct use of topical preparations on local formulary websites that can be downloaded and given to patents
  • Ensure that local referral guidelines identify indications for referral to specialist care, and how this can be accessed urgently if required
  • Include treatment of possible infected eczema in any local antimicrobial stewardship guidelines to avoid excessive antibiotic use.

STP=sustainability and transformation partnership; ICS=integrated care system

References

  1. NICE. Eczema—atopic: summary. NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/eczema-atopic/ (accessed 20 May 2021).
  2. Primary Care Dermatology Society. Atopic eczema. www.pcds.org.uk/clinical-guidance/atopic-eczema (accessed 25 May 2021).
  3. NICE. Eczema—atopic: NICE stepped approach to treatment. NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/eczema-atopic/prescribing-information/stepped-approach-to-treatment/ (accessed 20 May 2021).
  4. NICE. Atopic eczema in under 12s: diagnosis and management. Clinical Guideline 57. NICE, 2007 (last updated 2021). Available at: www.nice.org.uk/cg57
  5. NICE. Eczema—atopic: scenario, assessment. NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/eczema-atopic/management/assessment/ (accessed 20 May 2021).
  6. NICE. Eczema—atopic: emollients. NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/eczema-atopic/prescribing-information/emollients/ (accessed 20 May 2021).
  7. NICE. Eczema—atopic: topical corticosteroids. NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/eczema-atopic/prescribing-information/topical-corticosteroids/ (accessed 20 May 2021).
  8. NICE. Eczema—atopic: scenario, moderate eczema. NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/eczema-atopic/management/moderate-eczema/ (accessed 20 May 2021).
  9. NICE. Eczema—atopic: scenario, mild eczema. NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/eczema-atopic/management/mild-eczema/ (accessed 20 May 2021).
  10. NICE. Eczema—atopic: scenario, severe eczema. NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/eczema-atopic/management/severe-eczema/ (accessed 20 May 2021).
  11. NICE. Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing. NICE Guideline 190. NICE, 2021. Available at: www.nice.org.uk/ng190
  12. NICE. Eczema—atopic: what are the complications? NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/eczema-atopic/background-information/complications/ (accessed 20 May 2021).
  13. Lyons, J, Milner, J, Stone, K. Atopic dermatitis in children: clinical features, pathophysiology, and treatment. Immunol Allergy Clin North Am 2015; 35 (1): 161–183.
  14. NICE. Treatment of eczema herpeticum. Quality Statement 7: treatment of eczema herpeticum. Quality Standard 44. NICE, 2007 (last updated 2021). Available at: www.nice.org.uk/guidance/qs44/chapter/Quality-statement-7-Treatment-of-eczema-herpeticum