Dr Anthony Boggis reviews the NICE and PCDS/BAD guidelines on the management of atopic eczema in children, and outlines a summary process for care
  • Diagnose atopic eczema according to the criteria in the NICE guideline
  • Carry out a holistic assessment on the impact of the condition
  • Agree a stepped-management plan with the patient and parents/carers
  • Prescribe adequate quantities of emollient
  • Provide the appropriate potency of corticosteroid creams
  • Confirm patient and parent/carer understanding of the nature of eczema and the treatments prescribed
  • Consider the possibility of infection in flares and treat accordingly
  • Review the patient regularly if they have severe eczema
  • Refer the patient if the condition remains uncontrolled

Clinical guidelines are invaluable for a number of reasons: patients can check them to see if they are receiving the ‘correct’ treatment; doctors use them to audit their care against a gold standard, and also to satisfy appraisal and revalidation hurdles; and society, or more correctly primary care trusts need them to encourage cost-effective and standardised levels of care across the country. However, the number and length of such guidelines can make keeping up to date with best practice a challenge.

The full NICE guideline on Atopic eczema in children: management of atopic eczema from birth up to the age of 12 years extends to 196 pages and is extremely comprehensive;1 it is useful as a study guide, but not for regular use in day-to-day practice. It has been called practical,2 however I contend that its sheer size is daunting for all but the most committed healthcare professionals. The shorter version has 39 pages and the quick reference guide has 19 pages, both of which are still unlikely to endear them to frequent daily use. Any guidance needs to be accessible and easy to understand to be implemented successfully.

The Primary Care Dermatology Society (PCDS) and the British Association of Dermatologists (BAD) have co-produced a guideline on atopic eczema that covers both children and adults and extends to just four pages making it much more practical and likely to be implemented.3

In this article I have taken into account the NICE and PCDS/BAD recommendations and aimed to produce a streamlined process for managing atopic eczema in children, which can be used regularly in the practice.

The management of atopic eczema can be separated into six different areas:

  • Diagnosis
  • Holistic assessment
  • Development of a management plan
  • Education
  • Patient review
  • Referral.

Each of these areas is detailed below.

Diagnosis

The first step of any guideline should be to establish that the diagnosis is correct. A flowchart for the management of eczema in children based on the NICE guideline is shown in Figure 1, and a photograph of a typical case of atopic eczema appears in Figure 2a. In diagnosing atopic eczema, the healthcare professional should be aware that Asian, black Caribbean, and African children can present with the condition on extensor surfaces and in a discoid or follicular form (see Figure 2b).2

Figure 1: An algorithm for managing a child with atopic eczema

Figure 1: An algorithm for managing a child with atopic eczema
*Adapted from the stepped care plan in the Quick Reference guide for NICE Clinical Guideline 57 on the management of atopic eczema in children. Available at: www.nice.org.uk/guidance/CG57/QuickRefGuide/pdf/English.

Figure 2

a) Atopic eczma
Atopic eczma
b) Follicular pattern
Follicular pattern
c) Infected eczema Infected eczema d) Eczema herpeticum Eczema herpeticum
Figures 2a–2c reproduced courtesy of Professor Raimo Suhonen: dermnetnz.org/dermatitis/atopic-imgs.html
Figure 2d reproduced courtesy of www.dermnetnz.org/viral/herpes-simplex.html DermnetNz

 

Holistic assessment

A holistic approach should be taken in the assessment of atopic eczema.3 This should include assessment of the severity of disease and impact on the life of the child and their parents/carers (e.g. sleep disturbance, impact on daily activities, and psychosocial wellbeing). Eczema in children can fluctuate quickly and both the child and parents/carers need to understand how to step up and step down therapy.

Development of a management plan

Treatment of atopic eczema depends on severity and site (see Table 1).The long-term avoidance of irritants and the provision of adequate quantities of emollients are essential except for in the mildest presentations of atopic eczema. Patients and their parents/carers often find problems obtaining sufficient quantities of creams—a child may need as much as 250–500 g weekly.1,3 Doctors often feel uncomfortable providing very large quantities of these products, perhaps because of prescribing budgets or concern over emollient contamination. Yet one of the most frequent reasons patients or parents/carers arrange an appointment is because a flare up has occurred as a result of running out of emollient.

The same considerations apply to providing corticosteroid creams; quantities appropriate to the severity and extent of the disease need to be prescribed. Care needs to be taken regarding the frequency, quantity, and potency of product applied, particularly in certain areas, such as the face and neck, flexures, and genital regions. As a general rule, a patient of any age will require emollients in a ratio of about 10:1 against steroids.3 The PCDS/BAD guideline recommends that if corticosteroids are being used, these should be applied first, followed by emollients after an interval of 30 minutes.3 The emollient acts as a barrier and ‘traps’ the steroid next to the skin. However, there is an ongoing debate as to whether emollient should in fact be applied first, to hydrate the skin and improve steroid penetration.

Other possible treatments include:

  • Bandaging—this promotes absorption of steroids and emollients and acts as a barrier, thus preventing damage from scratching. It can take the form of wet wraps, dry wraps, and medicated bandages
  • Phototherapy and systemic therapies (ciclosporin, azathiaprine, and systemic steroids)—these may be tried under specialist care when conventional measures are inappropriate or have failed1
  • Antihistamines—these may be used in the short term for flares of eczema, particularly the sedating antihistamines, which may help the child and the family to sleep, but should be avoided long term because of worries about cognitive impairment and mood changes.

Table 1: Treatments for atopic eczema in children according to severity and site1

Site/Symptom Eczema severity
Mild Moderate Severe
Body
  • Emollients +/- mild potency topical corticosteroids
  • Emollients
  • Moderate potency topical steroids (use for axillae and groin flares for 7–14 days only)
  • Tacrolimus
  • Bandages
  • Emollients
  • Potent topical corticosteroids (use for axillae and groin flares for 7–14 days only)
  • Tacrolimus
  • Bandages
  • Phototherapy
  • Systemic therapy
Face and neck
  • Emollients +/- mild potency topical corticosteroids
  • Emollients
  • Mild potency topical steroids
  • For severe flares, use moderate potency topical corticosteroids for 3–5 days only
  • Topical calcineurin inhibitors
  • Bandages
  • Emollients
  • Tacrolimus
  • Bandages
  • Phototherapy
  • Systemic therapy
Itch
  • Antihistamines (sedating)
Infection
  • Oral or topical anti-staphylococcal antibiotic according to severity
National Institute for Health and Care Excellence (NICE) (2007) CG57. Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. London: NICE. Available from www.nice.org.uk/CG57 Reproduced with permission.

Education

Parent/carer and child education is vital to ensure appropriate treatment and ultimately aims to empower the child to manage their own eczema. The healthcare professional should listen to the parent and child, and address their fears and concerns with verbal and written information, and practical demonstrations on the use of emollients, steroids, and bandaging. Discussion should also cover the management of flares of eczema. An individualised management plan should be developed with input from the parent/child, taking into account variations in severity and sites of eczema, and the occurence of more severe flares.

Education of the child and their parents/carers should include recognition of the severity of eczema and how to adjust management accordingly; it should also raise their awareness of the importance of identifying and treating bacterial and viral infections.1 Patients may benefit from a handout detailing their individual management plan; this should include details on:

  • what to use when there are no flares
  • what to do if there is a flare up
  • when to seek medical advice.

Patient review

It is useful to offer an early review appointment to ensure that the eczema is improving on the agreed regimen. The review appointment is an opportunity to ‘step down’ therapy and for the child and their parents/carers to gain some extra assurance and education on the treatment being used.

Referral

Referral to a dermatologist should be considered if:1,3

  • the diagnosis is in doubt
  • the eczema fails to respond to standard stepwise therapy (refer urgently by phoning the consultant if the eczema is severe and not responding to topical therapy)
  • allergic contact dermatitis is suspected
  • there are significant psychosocial effects
  • the family might benefit from additional advice on the application of treatments
  • there is suspected food allergy
  • there is failure of growth (refer to paediatrician).

Infection

Infections are a common cause of flares of eczema (see Figure 2c) and should be treated aggressively using antibiotics against Staphylococcus aureus and streptococcus. Healthcare professionals should be prepared to swab the skin in recurrent infections or where there are concerns about antimicrobial resistance or unusual organisms. The application of topical antibiotic/steroid combinations is controversial because of fears over the development of antibiotic resistance, but they are still used by many specialists and general practitioners.3 These combinations should only be used for up to 2 weeks,1 and the use of emollients with antimicrobial action should be encouraged.

Eczema herpeticum forms closely clustered painful monomorphic vesiculopustules on an erythematous base, which rapidly develop a central depression that is often asymmetric initially (see Figure 2d, p.18). This is a potentially serious and even life-threatening complication that warrants immediate referral for specialist care.1,3

Challenges for health professionals

Allergies
Many parents/carers suspect allergies as the cause of the child’s eczema, and in particular food allergies. Often they request allergy tests that can usually be politely refused with the explanation that such tests are unhelpful, unless they can identify foods that produce immediate symptoms, or in cases of uncontrolled eczema despite the use of optimal therapy (especially if associated with bowel symptoms, such as colic, vomiting, altered bowel habit, or failure to thrive).1

Prescription quantities
As professionals, we need to encourage our colleagues to prescribe adequate quantities for the areas to be treated (perhaps up to 1 kg/month of emollient for a severely affected child,3,4 although it would be prudent to prescribe smaller quantities of steroid creams and use frequent patient reviews to assess response to treatment). The British National Formulary also contains guidance on suitable quantities of steroids to be prescribed for specific areas of the the body (NB these quantities relate to adults only).

Concern over using corticosteroids
Some patients and parents/carers are so afraid of the effects of corticosteroids that they will either not use them or use inadequate quantities, and much time needs to be devoted to exploring their fears and reassuring them on safety issues. There may be a role for using calcineurin inhibitors sooner in these groups (although the safety profile for these drugs is still incompletely determined), but the use of such therapies should be fully discussed before starting treatment.

Potency of steroid cream
Corticosteroid potency should be appropriate to the site of application (see Table 1), which may mean prescriptions for a variety of products with different strengths. Children and parents/carers will need careful explanations and instructions for the preparation label. Children who are using potent corticosteroids will require regular review; and repeat prescription should be avoided if a review has not been carried out. Very potent topical corticosteroids should be avoided in children.

Generic prescribing
The use of generic names can lead to confusion, which could result in harm; for example Eumovate® is clobetasone butyrate (moderate potency) while Dermovate® is clobetasol propionate (very potent).5 I would argue that this is an area where we can justify branded prescriptions to aid safety and concordance.

Conclusion

The NICE guideline on the management of atopic eczema is comprehensive and compelling, but in my opinion, does not appear to have had a substantial impact on care since its publication in 2007. The concise PCDS/BAD guideline is more practical for routine use.

Practitioners face a number of challenges in improving care for children with atopic eczema; these can be conquered with thought and effort. There appear to be no plans or indeed a need to revise these guidelines in the near future, but I would encourage the adoption of a streamlined version for regular use. I believe the sound messages in the NICE guideline need simplifying to encourage uptake and improve quality of care for children with eczema and their families. I hope this article goes some way towards helping implementation.

Useful information for patients

Printed patient information sheets from bodies such as the British Association of Dermatologists can be invaluable in reinforcing information imparted in the consultation. The following websites may also be useful resources for patients:
written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead
  • Most cases of eczema can be easily managed in primary care
  • Dermatology is ideal for community provision using GPwSIs, specialist nurses, or even directly employed consultant dermatologists
  • The algorithm could be used as a basis for local referral guidelines to consultant or community dermatology services
  • There is no national mandatory tariff for dermatology outpatients from April 2008—prices can be negotiated locally
  • Non-mandatory tariff price for single professional outpatient attendance = £118 (new), £58 (follow up)a
  1. National Collaborating Centre for Women’s and Children’s Health. Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. Clinical Guideline 57. London: NICE, 2007. Available at: www.nice.org.uk/guidance/CG57/
  2. Purdy S. Holistic care of children with atopic eczema is recommended by NICE. Guidelines in Practice 2008; 11 (2): 17–23. Available at: www.eguidelines.co.uk/eguidelinesmain/gip/vol_11/feb_08/purdy_eczema_feb08.php
  3. Primary Care Dermatology Society, British Association of Dermatologists. Guidelines for the management of atopic eczema. In: Foord-Kelcey G, editor. Guidelines—summarising clinical guidelines for primary care. 28th ed. Berkhamsted: MGP Ltd; February 2006. pp: 372–375.
  4. Champion R, Burton J, Burns T et al. Rook/Wilkinson/Ebling textbook of dermatology. Sixth edition. Oxford: Blackwell Scientific, 1998: 3530–3531.
  5. Joint Formulary Committee. BNF 57. London: BMJ Group and RPS Publishing, 2009.G