NICE guidance aids decision-making and enables clinicians to inform and educate children and their carers, says Dr Stephen Hayes
The NICE guideline on Atopic eczema in children was developed to assist clinicians in making diagnostic and management decisions about childhood atopic eczema and to provide information and education for children and their parents or carers.1,2
Evidence from meta-analyses, randomised controlled trials, case reviews, and expert consensus opinion was reviewed by a team of professionals, which included dermatologists, GPs, and pharmacists.
This article highlights those points of main interest to busy GPs, but the full report may be consulted for a more in-depth study.2
Definition of atopic eczema
The key features of atopic eczema (atopic dermatitis) are as follows:
- it is a chronic inflammatory itchy skin condition that usually starts in early childhood1,2
- it is one of a group of related inherited conditions that also includes asthma and hay fever2
- atopic eczema can make the skin dry, itchy, red, broken, and sore, with tiny clear vesicles present
- exacerbations are caused by irritants, infections, and allergens
- it is typically a disease of flares and remissions, but may be continuous
- the napkin area is usually unaffected2
- a few infants exhibit a discoid pattern (circular patches)
- in older children, flexural involvement predominates, as in adults.2,3
Stepped approach to management
A stepped approach should be used to manage atopic eczema in children, tailoring the treatment to each case.1,2
Step 1: Emollients, first and always
Emollients should always be used, even during remissions. Offer a choice suited to the child’s needs and preferences for daily use when moisturising, washing, and bathing. A combination of products may be ideal and it is important to try and find what works best for each child. The prescription should give sufficient quantity for use at home and at school (including nursery and preschool).1,2
Emollients keep moisture in and irritants out. Over 40 different products (ointments, creams, lotions, gels, and sprays) are listed in the BNF for Children.4 Ointments, such as white soft paraffin and liquid paraffin, are greasy, whereas creams and lotions contain water and are more acceptable cosmetically. Creams, lotions, and gels contain preservatives to protect against microbial growth in the presence of water. Antiseptics added to emollients include triclosan, chlorhexidine hydrochloride, and benzalkonium chloride.2 These sometimes cause stinging on application.
Step 2: Topical corticosteroids
Steroid potency should be tailored to severity, which may vary according to body site. The guideline makes several recommendations on their use, which are:1,2
- mild potency for mild eczema, and on the face and neck
- moderate potency for moderate eczema—and for short-term (3–5 days) on the face and neck in the case of severe flares
- potent topical corticosteroids for severe eczema
- moderate or potent preparations should only be used for short periods (7–14 days) for flares in vulnerable sites such as axillae and groin
- very potent steroids should not be used in children without specialist advice.
Steroid misuse can cause skin thinning, striae, or rosacea. Severe, prolonged overuse may lead to systemic absorption and Cushing’s syndrome, osteoporosis, or growth retardation.2 Fear of these side-effects is widespread and may cause worried parents to refuse treatment. Steroid phobia must be anticipated and explored to aid compliance. There is a strong clinical consensus that long-term use of a topical steroid within clinically recommended dosages is safe. More trials on topical corticosteroid use are called for.2
Step 3: Calcineurin inhibitors
Calcineurin inhibitors (e.g. tacrolimus, pimecrolimus) are immune suppressors like ciclosporin (which is not effective topically). They should only be initiated by doctors familiar with their use and who have a special interest and experience in dermatology.2 Calcineurin inhibitors often sting at first; and there is a theoretical increased long-term risk of a patient developing skin cancer. They are not recommended for mild disease or as first-line treatment, but may be very useful for patients with moderate-to-severe disease requiring prolonged steroid use.
Indications for referral
The NICE guideline recommends that specialist dermatological advice should be sought in some cases. These are:1,2
- in cases of diagnostic doubt
- where there is failure of control
- for severe facial eczema
- in cases of suspected contact allergy
- where there are significant social or psychological problems (e.g. sleep disturbance, poor school attendance, carer not coping).
Severe and intractable cases of atopic eczema should be managed in hospital by specialists. Options such as azathioprine, ciclosporin, methotrexate, mycophenolate, oral prednisolone, and the newer biological agents and ultraviolet light may sometimes be employed. The guideline noted a lack of randomised controlled trials looking at safety, effectiveness, and cost of such options.2
Parents should be advised on the symptoms and signs of bacterial infection (with streptococcus or staphylococcus). These include:1
- rapidly worsening eczema
- eczema not responding to therapy.
Oral flucloxacillin is the recommended first-line treatment, erythromycin or clarithromycin are alternatives. Topical antibiotics, including those combined with topical corticosteroids, should be reserved for clinical infection in localised areas. Use should be limited to no longer than 2 weeks, because of the risk of bacterial resistance developing.1,2
Sudden worsening of eczema, a feverish and ill child, rapidly spreading blisters and uniform erosions of 1–3 mm are indicative of eczema herpeticum. If it is suspected, treatment with systemic aciclovir should be started immediately and the child should be referred for same-day specialist dermatological advice.1,2 Concomitant staphylococcal infection may occur; involvement of the skin around the eyes is particularly dangerous and affected children should also be referred for same-day ophthalmological advice.
Food allergy should be considered in children who have reacted to a food with immediate symptoms. Most children with atopic eczema will not have food allergy. High street and internet allergy tests should be avoided as there is no evidence of benefit from them. Exclusion diets rarely help and they should only be tried on specialist dietary advice.1,2
Eczema can clearly affect the child’s mental state and social functioning as well as that of their family. As scratching is part of the problem, scratch reduction through a behavioural approach has been advocated, but there is no good evidence of benefit. Further studies on behavioural and psychological aspects of atopic eczema are called for.2
Antihistamines and antipruritics
There are no data to support the efficacy of antihistamines in the treatment of eczema, but they are widely used. A 1-month trial of non-sedating antihistamine is reasonable in severe cases, or for children with mild or moderate atopic eczema where there is severe itching or urticaria. This may be continued if it is successful.1,2 In my experience, however, non-sedating antihistamines rarely, if ever, help, but a sedating antihistamine such as chlorpheniramine may give some relief at night, if only to let mum sleep and reduce scratching. It is logical to keep fingernails ultra short and smooth to minimise self-inflicted damage from scratching.
Complementary and alternative medical therapies
There are almost no data on the effectiveness of complementary and alternative medical (CAM) treatments, although up to 60% of parents may have tried them. Parents should be asked about CAM use; none of it has good trial evidence and some may be harmful, for example some Chinese herbal medicines for eczema have been found to contain dexamethasone.2,5 Relapse may also result if CAM practitioners advise patients to stop using effective conventional treatments.
Atopic eczema is a common and important disease of children causing significant morbidity and family distress. Most eczema can be managed in primary care, but due to the insufficient time spent on skin disease in medical education, it is not always optimally managed.
This guideline is too long and detailed for most GPs but will help those with a special interest. The key things for GPs to remember are that:
- emollients should always be used, even during remissions—try until you find what works
- patients should be reassured
- availability of professional advice is important
- children, parents and carers should be educated about the condition
- corticosteroids should be used cautiously but confidently.
Do not be afraid to refer if you are not winning.
- National Institute for Health and Care Excellence. 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.
- 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. London: NCCWCH, 2007.
- Friedmann P, Holden C. Atopic dermatitis. In: Burns D, Braethnach S, Cox N, Griffiths C, eds. Rook’s Textbook of Dermatology, 7th edition. Oxford; Blackwell Publishers: 2004.
- British Medical Association, the Royal Pharmaceutical Society of Great Britain, the Royal College of Paediatrics and Child Health, and the Neonatal and Paediatric Pharmacists Group. BNF for Children (BNFC). London: BMJ Publishing Group, RPS Publishing, and RCPCH Publications Ltd: 2007.
- Keane F, Munn S, du Vivier A et al. Analysis of Chinese herbal creams prescribed for dermatological conditions. Br Med J 1999; 318 (7183): 563–564.G