NICE has published Referral Advice – a guide to approriate referral from general to specialist services, which deals with 11 common complaints. Last month we covered the guidance on acute low back pain; in this issue we reproduce the advice on atopic eczema in children.
The referral advice is set out in consensus statements based on the best available evidence. It is designed to help clinicians determine how urgently particular patients need to be referred. For a summary of the consensus statements follow this link.
Atopic eczema is common and its prevalence is increasing. It affects up to 15% of children and accounts for around one third of dermatological consultations in general practice. It usually starts in the first years of life and in over 60% of children will have cleared by the time they reach their teens.
The condition, which generally waxes and wanes, is itchy, often unsightly and can lead to secondary complications (such as infection). It can also cause sleep disturbance, family disruption and loss of self-esteem. Atopic eczema presents as an itchy, patchy, erythematous rash, often with excoriation and bleeding.
A diagnosis of atopic eczema is very likely if the child has an itchy skin condition plus three or more of the following:
- history of involvement of the skin creases such as folds of elbows, behind the knees, fronts of ankles or around the neck (including cheeks in young children)
- a personal history of asthma or hay fever (or history of atopic disease in a first-degree relative in young children)
- a history of a general dry skin
- visible flexural eczema (or eczema involving the cheeks/forehead and outer limbs in young children)
- onset under the age of 2 years.
Eczema may be exacerbated by local infection (bacterial or viral), irritants (such as soaps, woollens or rough clothing), allergens (such as house dust mite, occasionally contact allergens and rarely dietary constituents) or stress.
Although treatment is not curative, it usually reduces symptoms and can considerably improve the quality of life of child and family.
Treatment may typically include emollients and topical corticosteroids of appropriate strengths and quantities (see British National Formulary, Section 13.4) given for defined periods. Antibiotics are used for patients with suspected secondary bacterial infection and oral aciclovir for suspected herpes simplex infection.
Bandaging (such as wet wraps or zinc paste) and sedative antihistamines are also used.
These are in a position to:
- confirm or establish the diagnosis
- provide inpatient care or care in a day-treatment centre
- optimise treatment regimens
- explain and give advice to parents and patients on treatments that are available and demonstrate how they should be used; offer the family and patient support and counselling as necessary
- provide and support specialist nursing services working in primary and secondary care
- provide and supervise treatment in patients with severe disease who may require phototherapy (UVB, PUVA) or immunosuppressive therapy
- patch-test patients with suspected superimposed contact allergic dermatitis (in practice this test is rarely required)
- provide dietary assessment and supervision of an exclusion diet on the rare occasions these are needed.
Most children with atopic eczema can be managed in primary care. Referral to a specialist service, which may be prompted by features such as sleep disturbance and school absenteeism, is advised if:
infection with disseminated herpes simplex (eczema herpeticum) is suspected
|the disease is severe and has not responded to appropriate therapy in primary care|
|the rash becomes infected with bacteria (manifest as weeping, crusting, or the development of pustules), and treatment with an oral antibiotic plus a topical corticosteroid has failed|
|the rash is giving rise to severe social or psychological problems|
treatment requires the use of excessive amounts of potent topical corticosteroids
|management in primary care has not controlled the rash satisfactorily. Ultimately, failure to improve is probably best based upon a subjective assessment by the child or parent|
|the patient or family might benefit from additional advice on application of treatments (e.g. bandaging techniques)|
|contact dermatitis is suspected and confirmation requires patch-testing (this is rarely needed)|
|the child has uncontrolled eczema and dietary factors are suspected (refer directly to a dietician)|
|The starring system developed by NICE to identify referral priorities|
Arrangements should be made so that the patient:
|is seen immediately1|
|is seen urgently2|
|is seen soon2|
|has a routine appointment2|
|is seen within an appropriate time depending on his or her clinical circumstances (discretionary)|
1 within a day
2 health authorities, trusts and primary care organisations should work to local definitions of maximum waiting times in each of these categories. The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks to be appropriate for the urgent category.
Reproduced with kind permission from: Referral Advice – A Guide to Appropriate Referral from General to Specialist Services. London: NICE, December 2001.
The complete document can be downloaded from the NICE website www.nice.org.uk