The evidence-based guidance will support GPs in their treatment decisions and help them improve the quality of life of children in their care, says Dr Sarah Purdy

The management of childhood atopic eczema is part of the day-to-day routine of the general practice. However, although the majority of eczema seen in primary care is mild (80%),1 it can have a profound effect on the quality of life of children and their families. The implementation of new treatments, such as calcineurin inhibitors, widens the range of treatment options available to GPs. They also need to adopt a holistic approach to the management of children with eczema and have the knowledge to advise increasingly interested parents about factors that can exacerbate eczema and whether they should make changes to lifestyle, breastfeeding, or diet. The publication of NICE Clinical Guideline 57 on Atopic eczema in children is good news for children with the condition, their families, and the clinicians involved in their care management.1,2

Why childhood atopic eczema is important

Childhood atopic eczema is a common condition: a recent UK study reported a lifetime prevalence of 23% in children aged 12 years.3 This is reflected in the number of consultations for dermatological conditions, which account for 15% of GP appointments.4 Of these, 22% are for eczema (one in 30 GP consultations).4 However, despite the frequency with which these conditions present, most GPs have received little training in dermatology.5

Atopic eczema can have a profound negative effect on the quality of life of the child and his or her family, causing sleep disturbance, affecting psychological wellbeing, and impacting on the child’s participation in usual daily activities at home and at the nursery or school.1,2 The extent of this should never be underestimated and it is an underlying principle of the new NICE guideline that the impact of the eczema on the child and his or her family should be considered at every assessment with a healthcare professional.1,2

What is atopic eczema?

Atopic eczema, or atopic dermatitis, is a chronic inflammatory itchy skin condition. In the majority of cases it develops in early childhood and is typically an episodic disease. Patients usually experience periods of exacerbation (flares, possibly two or three per month) and remission, although in some cases it may be continuous. Atopic eczema has a genetic component that leads to the breakdown of the skin barrier and makes it susceptible to trigger factors that can make the eczema worse, including irritants and allergens.1,2

Atopic eczema often clears up or improves during childhood, but it can persist into adulthood. It can be associated with the development of asthma and/or allergic rhinitis; a sequence of events known as the ‘atopic march’.1,2

About the NICE guideline

The NICE guideline Atopic eczema in children: the management of atopic eczema in children from birth up to the age of 12 years1,2 has been developed with the aim of providing guidance on:

  • diagnosis and assessment of the impact of the condition
  • management during and between flares
  • information and education for children and their parents or carers about the condition.

The guideline is available in several formats: the full guideline gives details of the methods and the evidence used to develop the guidance;1 the NICE guideline provides a summary of the guidance;2 there is a quick reference guide for clinicians; and also a version for parents and carers.6,7

This article will focus on key recommendations for primary care clinicians and other non-specialist healthcare professionals involved in the care of children with atopic eczema.

Child-centred care

Treatment and care should take into account the needs and preferences of the child, as well as those of his or her parents or carers. Children with atopic eczema and their parents or carers should have the opportunity to be involved in decisions about care and treatment in partnership with their GP and other primary care clinicians.1,2

Good communication between clinicians and children and their parents or carers is essential. It should be supported by evidence-based written information tailored to the needs of the individual child.1,2

Assessment of severity, psychological and psychosocial wellbeing and quality of life

The healthcare professional should adopt a holistic approach when assessing a child’s atopic eczema at each consultation, taking into account the severity of the condition, the child’s quality of life, including everyday activities and sleep, and his or her psychosocial wellbeing (see Table 1). It is important to remember that there is not necessarily a direct relationship between the severity of the atopic eczema and its impact on quality of life.1,2

Identification and management of trigger factors

Atopic eczema is worsened by trigger factors and the healthcare professional should try to identify potential trigger factors when assessing the child. He or she should be advised to avoid:1,2

  • irritants—soaps and detergents such as shampoos, bubble baths, shower gels, and washing-up liquids
  • skin infections
  • contact allergens
  • food allergens
  • inhalant allergens.

Many parents are concerned about food allergy in children with atopic eczema. The healthcare professional should consider food allergy in:

  • children with atopic eczema who have previously exhibited an immediate reaction to a food
  • infants and young children with moderate or severe atopic eczema that has not been controlled by optimum management, particularly if associated with gut dysmotility (colic, vomiting, altered bowel habit) or failure to thrive.

It is important to reassure the parents of children with mild atopic eczema that most children with a mild form of the condition do not need clinical testing for allergies. The guideline from NICE also advises against giving children high street or internet allergy tests because there is no evidence of their value in the management of atopic eczema.1,2

Table 1: Holistic assessment

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
National Institute for Health and Care Excellence (NICE) (2007) CG 57 Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. Reproduced with permission. Available from

Stepped approach to management

The NICE guideline recommends that a stepped approach be taken to managing atopic eczema in children, tailoring the treatment step to the severity of the child’s condition. Atopic eczema management should be based on continual emollient use, even when the atopic eczema is clear. Table 2 shows other treatments that can be added to management of the atopic eczema so that it can be stepped up or down, according to the severity of symptoms.1,2

The stepped approach and the recommendations in the guideline have been developed into an algorithm, which is included in the quick reference guide.6

Table 2: Stepped approach to treatment

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
National Institute for Health and Care Excellence (NICE) (2007) CG 57 Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. Reproduced with permission. Available from

Managing flares

The NICE guideline recommends that healthcare professionals advise children with atopic eczema and their parents or carers to look out for signs of a flare of their eczema. They should look for:

  • increased dryness
  • itching
  • redness
  • swelling
  • general irritability.

Clear instructions should be given to children and their parents or carers on how to manage flares according to a stepped-care plan. The healthcare professional should prescribe treatments that help them to follow this plan.1,2 Although the stepped-care plan is new in childhood eczema, this concept of stepping up and down and patient self-management will be familiar to GPs and practice nurses who are used to managing patients with other chronic diseases, such as asthma, in primary care.


It is important that clinicians offer children with atopic eczema a choice of unperfumed emollients to use every day for moisturising, washing, and bathing.This is common practice in dermatology clinics but not easy to deliver in primary care where samples of emollients are not readily available. However, emollients should suit the child’s needs and preferences, and may include a combination of products or one product for all purposes. Emollients that are left on the skin should be prescribed in large quantities (250–500 g weekly) and should be easily available to use at nursery, pre-school or school.1,2

Topical corticosteroids

Many parents are concerned about the use of topical corticosteroids in children, especially on the face. However, the guideline has clear recommendations that should reassure parents. In summary, the potency of topical corticosteroids should be tailored to the severity of the child’s atopic eczema, which may vary according to whereabouts on the body it is.1,2 Depending on the severity, use:

  • mild potency for mild atopic eczema
  • moderate potency for moderate atopic eczema
  • potent for severe atopic eczema
  • mild potency for the face and neck, except for short-term use (3–5 days) of moderate potency topical corticosteroids for severe flares
  • moderate or potent preparations for short periods only (7–14 days) for flares in vulnerable sites such as axillae and groin.

Very potent corticosteroid preparations should not be used in children without specialist dermatological advice.

Treatment of infections

Flares of atopic eczema are often caused by infection. Symptoms and signs of bacterial infection with staphylococcus and/or streptococcus that children with the condition and their parents or carers should be advised to look out for include:

  • weeping
  • pustules
  • crusts
  • atopic eczema failing to respond to therapy
  • rapidly worsening atopic eczema
  • fever
  • malaise.

Parents and carers should be given clear information on how to access appropriate treatments when their child’s atopic eczema becomes infected.1,2 Recommended treatments for bacterial infection are listed in Table 3.

Table 3: Treatment of bacterial infections

Treatment Use for Time
Systemic antibiotics active against Staphylococcus aureus and streptococcus Widespread bacterial infections 1–2 weeks
Topical antibiotics, including those combined with topical corticosteroids Localised clinical infection Maximum of 2 weeks
Flucloxacillin First-line treatment of S. aureus and streptococcal infections As indicated
Erythromycin First-line treatment of S. aureus and streptococcal infections in the case of allergy to flucloxacillin or flucloxacillin resistance As indicated
Clarithromycin First-line treatment of S. aureus and streptococcal infections in the case of allergy to flucloxacillin, flucloxacillin resistance and intolerance to erythromycin As indicated
Antiseptics such as triclosan or chlorhexidine Adjunct therapy for decreasing bacterial load in cases of recurrent infected atopic eczema Avoid long-term use
National Institute for Health and Care Excellence (NICE) (2007) CG 57 Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. Reproduced with permission. Available from

Eczema herpeticum

Eczema herpeticum is diagnosed when eczema becomes infected with the herpes simplex virus and is a potentially life-threatening condition. Signs of eczema herpeticum are:1,2

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

Parents should be made aware of the need to seek medical advice as soon as possible if these signs develop. Treatment with systemic aciclovir should be started immediately (even in the case of localised infection), and same-day referral to a dermatologist should be made if eczema herpeticum is suspected. If secondary bacterial infection is thought likely, the child should also be treated with appropriate systemic antibiotics. In the case of eczema herpeticum affecting the skin around the eyes, the child should be treated with systemic aciclovir and should be referred for same-day ophthalmological and dermatological advice.1,2

Education and adherence to therapy

The NICE guideline advises the importance of educating children with atopic eczema and their parents or carers about the condition and how it is treated.

Healthcare professionals should give them verbal and written information, and practical demonstrations. Topics to cover are:1,2

  • how much of the treatments to use
  • how often to apply treatments
  • when and how to step treatment up or down
  • how to treat infected atopic eczema.

These areas should be reinforced at every consultation, addressing factors that affect adherence to treatment.1,2

Indications for referral

The indications for referral for specialist dermatological advice (usually to a dermatology department or to a GP with a special interest) in the NICE guideline differ slightly from previous recommendations from the Primary Care Dermatology Society and British Association of Dermatologists.8

The recommendations in the NICE guideline on Atopic eczema in children are to refer if:

  • the diagnosis is, or has become, uncertain
  • management has not controlled the atopic eczema satisfactorily based on a subjective assessment by the child, parent, or carer (for example, the child is having 1–2 weeks of flares per month or is reacting adversely to many emollients)
  • atopic eczema on the face has not responded to appropriate treatment
  • the child or parent/carer may benefit from specialist advice on treatment application (for example, bandaging techniques)
  • contact allergic dermatitis is suspected (for example, persistent atopic eczema or facial, eyelid, or hand atopic eczema)
  • the atopic eczema is giving rise to significant social or psychological problems for the child or parent/carer (for example, sleep disturbance, poor school attendance)
  • atopic eczema is associated with severe and recurrent infections, especially deep abscesses or pneumonia
  • a child with atopic eczema has followed a diet free from cow’s milk for longer than 8 weeks (for specialist dietary advice).

Improving care for children with atopic eczema

The new NICE guideline provides a practical, child-centred resource for GPs and other clinicians who care for children with atopic eczema. Much of the information will be familiar to GPs, but it is helpful to have evidence-based guidance to support treatment decisions and improve the quality of life for children and their families. Where little or no evidence was found, the recommendations are based on the consensus view of the guideline development group.1


This work was undertaken by the guideline development group on behalf of the National Collaborating Centre for Women’s and Children’s Health, which received funding from the National Institute for Health and Care Excellence. The views expressed in this publication are those of the authors and not necessarily those of the Institute.

  • Most cases of eczema can be easily managed in primary care
  • Referral to specialist care is indicated when control cannot be achieved in primary care
  • Dermatology is ideal for community provision using GPwSIs or employed dermatologists
  • There is no national mandatory tariff for dermatology outpatients from April 2008—prices can be negotiated locally
  • Indicative prices to inform local negotiation are £127 for first outpatient appointment; £70 for a follow upa
  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. London: NCC-WCH, 2007.
  2. 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.
  3. Burr M, Wat D, Evans C et al; British Thoracic Society Research Committee. Asthma prevalence in 1973, 1988 and 2003. Thorax 2006; 61 (4): 296–299.
  4. Kerr O, Benton E, Walker J et al. Dermatological workload: primary versus secondary care. Br J Dermatol 2007; 157 (suppl 1): 1–9.
  5. Schofield J, Adlard T, Heatley P, Gunn S. A study of the dermatological knowledge of general practitioner (GP) registrars: implications for GP training programmes. Br J Dermatol 2003; 149 (suppl 64): 19–56.
  6. 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. Quick reference guide. London: NICE, 2007.
  7. National Institute for Health and Care Excellence. Understanding NICE guidance: atopic eczema in children up to 12 years. London: NICE, 2007.
  8. 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, 2006.G