Dr Matthew Ridd summarises the NICE quality statements for atopic eczema in children and the key aspects of care for improving management of this common condition

Atopic eczema (atopic dermatitis) is a common, chronic, itchy skin condition, which usually develops in early childhood.1 It affects around 20% of children and carries an economic burden comparable with that of asthma.2 The original NICE clinical guideline (CG57) on Management of atopic eczema in children from birth up to the age of 12 years (see www.nice.org.uk/cg57) was published in 2007,3 and a review in 2011 confirmed that the recommendations were current at that time.4

The NICE quality standard (QS) for Atopic eczema in children (QS44) (see www.nice.org.uk/qs44), issued in September 2013, comprises seven concise statements designed to help improve the care and treatment of children with eczema (see Table 1).1 This article provides the background to the development of this quality standard, summarises the quality statements, and discusses how they are aligned with existing guidance.

Table 1: Quality standard for atopic eczema in children (QS44)1
No. Quality statement
1 Children with atopic eczema are offered, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.
2 Children with atopic eczema are offered treatment based on recorded eczema severity using the stepped-care plan, supported by education.
3 Children with atopic eczema have their (and their families’) psychological wellbeing and quality of life discussed and recorded at each eczema consultation.
4 Children with atopic eczema are prescribed sufficient quantities (250–500 g weekly) from a choice of unperfumed emollients for daily use.
5 Children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema are referred for specialist dermatological advice.
6 Infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment are referred for specialist investigation to identify possible food and other allergies.
7 Children with atopic eczema who have suspected eczema herpeticum receive immediate treatment with systemic aciclovir and are referred for same-day specialist dermatological advice.

The majority of children with eczema are diagnosed and managed exclusively in general practice.5 Although in most children eczema is mild and improves as the child grows older, the psychosocial impact on the family can seem at odds with the apparent physical severity of the condition.6

Traditionally, the undergraduate and postgraduate dermatology training of GPs and other generalists (e.g. clinicians in emergency departments) who may be involved in the care of children with atopic eczema, has been patchy. NICE CG57, and its implementation as a NICE pathway (see pathways.nice.org.uk/pathways/atopic-eczema-in-children),7 provides a valuable reference on best practice across the whole clinical pathway for atopic eczema in children. The quality statements prioritise areas of care with scope for quality improvement, and can be audited. By comparing individual and group (i.e. practice or hospital department) level achievements, clinicians can identify areas where attainment is short of the aspirational statements in the quality standard. They can then seek training or make changes that will ultimately improve patient care.

Assessment at diagnosis—statement 1

Making the diagnosis and explaining it to carers underpins all subsequent management. The cardinal symptoms of eczema are dry skin and itch. Potential trigger factors and clinical and treatment history should be assessed and recorded at diagnosis, with questions asked about:

  • when symptoms first developed, and the pattern and severity of the condition
  • what interventions have been tried already (including over-the-counter/internet products) and the treatment response
  • what changes, if any, have been made to the child’s diet
  • who else in the family has atopic disease
  • whether there are any concerns about the child’s general growth and development.

Early identification of trigger factors will inform the management of atopic eczema and improve disease severity. Healthcare professionals should ask about possible irritants and allergens, including:3

  • soaps and detergents (including shampoos, bubble baths, shower gels, and washing-up liquids)
  • skin infections
  • contact allergens (including topical treatments, especially if previously controlled eczema worsens)
  • food allergens (see statement 6)
  • inhalant allergens (may be particularly relevant if symptoms are seasonal).

As part of the assessment, clinicians should seek to educate parents that the approach to management of eczema is one of ‘control not cure’.7

Assessment of severity and stepped approach to management—statements 2 and 3

Quality statements 2 and 3 are interlinked, and are based on the NICE recommendation that there should be a holistic approach to the assessment of atopic eczema;1,3 that is, clinicians should take into account both the physical severity of the eczema and the impact on the child and their family. Even physically mild eczema can have a negative impact on psychological and psychosocial wellbeing and quality of life, causing problems such as sleep disturbance or poor attendance at school (see Table 2).

Treatment should be tailored according to the physical severity of atopic eczema, with advice (verbal and written) for children and carers on adherence and self-management, stepping treatment up and down as needed (see Table 3).3 Severity can vary across different body sites, and each area should be treated accordingly (e.g. mild potency topical corticosteroid for mild eczema in one area, and moderate potency topical corticosteroid for moderate eczema in another). Treatment for flares of atopic eczema in children should be started as soon as signs and symptoms appear and continued for approximately 48 hours after symptoms subside.3

Education on the use of, and adherence to, treatment is essential to the stepped-care plan approach.1 Children and carers should be given information and advice, with practical demonstrations, on:3

  • how much of each treatment they should be using
  • how topical treatments should be applied
  • when and how to step treatment up or down
  • how to recognise and treat infected atopic eczema.

This advice should be reinforced at every consultation, addressing any factors that affect adherence.3

Table 2: Holistic assessment3
Skin/physical severity Impact on quality of life and psychosocial wellbeing
Clear Normal skin, no evidence of active atopic eczema None No impact on quality of life
Mild Areas of dry skin, infrequent itching (with or without small areas of redness) Mild Little impact on everyday activities, sleep, and psychosocial wellbeing
Moderate Areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening) Moderate Moderate impact on everyday activities and psychosocial wellbeing, frequently disturbed sleep
Severe Widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking, and alteration of pigmentation) Severe Severe limitation of everyday activities and psychosocial functioning; nightly loss of sleep
  • NICE. Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. Clinical Guideline 57. NICE, 2007.
  • Reproduced with permission.
Table 3: Treatment escalator 3
Mild atopic eczema Moderate atopic eczema Severe atopic eczema
Emollients Emollients Emollients
Mild potency topical corticosteroids Moderate potency topical corticosteroids Potent topical corticosteroids
Topical calcineurin inhibitors Topical calcineurin inhibitors
Bandages Bandages
Systemic therapy
  • NICE. Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. Clinical Guideline 57. NICE, 2007.
  • Reproduced with permission.

Provision of emollients—statement 4

Emollients are the foundation of effective management in eczema, and children should have sufficient quantities (250–500 g weekly) for everyday moisturising, washing, and bathing.1 The emollients should always be used, even when the atopic eczema is clear. The prescribed emollient(s) should be unperfumed, and suited to the child’s needs and preferences.1,3 If an emollient causes irritation or is not acceptable to a child or their family, then an alternative product should be prescribed.

Co-prescribing different emollients for use at different times of the day or year may be appropriate. Aqueous cream is no longer recommended by many dermatologists as a leave-on emollient, because of concerns about frequency of skin irritation, and following recent MHRA guidance on its use.9

Referral for specialist advice and investigation—statements 5 and 6

Statements 5 and 6 of NICE QS44 relate to the referral of a child with moderate or severe atopic eczema that has not been controlled by optimal treatment. These children should be referred to a specialist with experience of, or qualifications in, paediatric dermatology, for example a:1

  • dermatologically trained paediatrician
  • specialist nurse
  • GP with a specialist interest
  • paediatric allergist or paediatric dermatologist (if allergy advice is needed).

Reasons to refer for specialist dermatological advice include:3

  • uncontrolled or unresponsive atopic eczema (including as assessed by the child, parent, or carer)
  • recurrent infections
  • suspected contact allergic dermatitis
  • if the physical condition is giving rise to significant social or psychological problems for the child (or their family).

A diagnosis of food allergy should be considered in:3

  • children with atopic eczema if they have reacted previously to a food, with immediate symptoms
  • infants and young children (under 1 year) with moderate or severe atopic eczema that has not been controlled by optimum management, particularly if associated with gut dysmotility (e.g. colic, vomiting, altered bowel habit) or faltering growth.

The most common food allergens for infants and young children with atopic eczema are:1

  • cows’ milk
  • hens’ eggs
  • nuts.

Specialist investigation can provide:1

  • accurate identification of common food and other allergens
  • advice on dietary avoidance and choice of infant formula
  • improved condition management strategies.

Treatment of eczema herpeticum—statement 7

Eczema herpeticum (widespread herpes simplex virus) is an uncommon but serious condition, which, if not diagnosed and treated promptly, can be fatal. For this reason, clinicians should be alert to the following signs:1

  • areas of rapidly worsening, painful eczema
  • clustered blisters consistent with early-stage cold sores
  • punched-out erosions (circular, depressed, ulcerated lesions), usually 1–3 mm that are uniform in appearance (these may coalesce to form larger areas of erosion with crusting)
  • possible fever, lethargy, or distress.

Children with suspected eczema herpeticum should receive immediate treatment and be referred for urgent (same-day) specialist dermatological advice.1,3 Oral or intravenous aciclovir can be given, depending on the clinical situation.1 NICE CG57 recommends that if a child with atopic eczema has a lesion on the skin suspected to be herpes simplex virus, treatment with oral aciclovir should be started, even if the infection is localised.3

NICE QS44 for atopic eczema in children1 does not replace NICE CG57,3 or other recognised guidance such as that produced by the Scottish Intercollegiate Guidelines Network (SIGN) on the management of children with atopic eczema (SIGN 125),10 which is consistent with and complements NICE CG57.

The full version of NICE CG573 is a comprehensive document that covers the whole clinical pathway for children with atopic eczema, while the seven quality statements in QS44 represent a distillation of the priority areas for quality improvement.

For many children with eczema and their carers, the basics of how to manage eczema (regular application of good quantities of emollients, and safe use of appropriate-strength topical corticosteroids) go a long way; this is reflected in the comments of the lay members of the Topic Expert Group that helped develop this quality standard (see Box 1). Holistic assessment of the child and recognition of when onward referral is necessary (and the urgency of that referral, in the case of eczema herpeticum), will help ensure that children receive appropriate care and specialist attention when needed.

Box 1: Some perspectives of parents of children with atopic eczema

Amanda Roberts and Jacqueline Torley offer their perspective on looking after children with eczema and how the NICE quality standard on atopic eczema in children (QS44) will help to improve care

This quality standard was needed because it helps to focus on the most important recommendations from the guideline, which should make it easier for clinicians to make a real difference to the lives of young patients with eczema, and their carers. Never has the saying "a stitch in time saves nine” been more true than in the care of this common condition which can have a huge impact.’ Amanda Roberts, lay member of the Topic Expert Group for NICE QS44

As a parent of children with eczema (and food allergies), I know only too well how important it is to receive appropriate and timely advice. I believe that the quality standard will be a useful tool to assist all healthcare professionals in delivering a consistent, high-quality service to those children who may suffer from the condition. The eventual seven standards were developed from the guideline, ensuring that they incorporated the absolute key aspects of care and assessment and their measurable outcome.’ Jacqueline Torley, lay member of the Topic Expert Group for NICE QS44

  • Proportion of children with atopic eczema:
    • whose assessment includes detailed information on clinical history, treatment, and potential trigger factors
    • who have their eczema severity recorded at each eczema consultation
    • who receive treatment based on recorded eczema severity using the stepped-care plan, and supported by education
    • who are prescribed sufficient quantities (250–500 g weekly) of unperfumed emollients for daily use
  • Proportion of:
    • consultations for children with atopic eczema at which their (and their families’) psychological wellbeing and quality of life is discussed
      and recorded
    • children with uncontrolled or unresponsive atopic eczema (including recurring infections or psychosocial problems related to the atopic eczema) who are referred for specialist dermatological advice
    • infants and young children with moderate or severe atopic eczema who have not been controlled by optimal treatment and who are referred for specialist investigation to identify possible food and other allergens
    • children with atopic eczema and suspected eczema herpeticum infection who receive immediate treatment with systemic aciclovir and are referred for same-day specialist dermatological advice.
  • CCGs should review this quality standard and ensure that their commissioned services meet the recommendations in the quality statements
  • It is likely that improvements can be made to the general practice management of eczema
  • A locally led care pathway approach for eczema, with an agreed template self-management plan, could help achieve many of these quality statements and reduce inappropriate referrals to secondary care
  • CCGs could, in collaboration with local specialist colleagues, lead a local education programme for general practices around the quality standard and local care pathway
  • Specialist paediatric dermatology nurses could be commissioned to link between primary care services and specialist care and help support eczema care in general practices
  • CCGs should:
    • identify cost-effective products for eczema in local formularies
    • provide guidance on the quantities that should be prescribed for children of different ages, to ensure sufficient emollients are prescribed in each case.
  1. NICE website. Atopic eczema in children. Quality Standard 44. www.nice.org.uk/guidance/QS44 (accessed 14 November 2013).
  2. Mancini A, Kaulback K, Chamlin S. The socioeconomic impact of atopic dermatitis in the United States: a systematic review. Pediatric Dermatology 2008; 25 (1): 1–6.
  3. NICE. Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. Clinical Guideline 57. NICE, 2007. Available at: www.nice.org.uk/cg57 nhs_accreditation
  4. NICE. Review of Clinical Guideline 57—management of atopic eczema in children. NICE, 2011. Available at: www.nice.org.uk/nicemedia/live/11901/55943/55943.pdf
  5. Schofield J, Grindlay D, Williams H. Skin conditions in the UK: a health care needs assessment. Nottingham: Centre of Evidence Based Dermatology, University of Nottingham, 2009.
  6. Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. Int J Clin Pract 2006; 60 (8): 984–992.
  7. NICE pathways website. Atopic eczema in children overview. pathways.nice.org.uk/pathways/atopic-eczema-in-children (accessed 14 November 2013).
  8. Santer M, Burgess H, Yardley L et al. Experiences of carers managing childhood eczema and their views on its treatment: a qualitative study. Br J Gen Pract 2012; 62 (597): e261–e267.
  9. Medicine and Health Products Regulatory Agency. Aqueous cream: may cause skin irritation, particularly in children with eczema, possibly due to sodium lauryl sulfate content. Drug Safety Update, Volume 6, Issue 8, March 2013. Available at: www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON254804
  10. Scottish Intercollegiate Guidelines Network. Management of atopic eczema in primary care. SIGN 125. Edinburgh: SIGN, 2011. Available at: www.sign.ac.uk/guidelines/fulltext/125/index.html nhs_accreditation G