Eczema management
Background
Atopic eczema (AE) or atopic dermatitis (AD) is a dry, itchy, inflammatory, chronic skin disease that typically begins in early childhood, affecting around 30% of children. This condition can worsen and cause intractable pruritus, soreness, infection and sleep disturbance. The onset of eczema is usually before 12 months and it follows a remitting and relapsing course. Most children will "grow out of" eczema before five years of age. There is no cure of AE, however if treated and managed well the disease has less impact on daily living and is less likely to have a negative effect on quality of life for the patient and family.
A summary of this guidance can be found by clicking the symbol in the Eczema Treatment Plan.
Assessment
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Erythema: redness of the skin
Discoid eczema: disc shaped, clearly demarcated eczematous patches to limbs and trunk.
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The UK Diagnostic Criteria for atopic eczema are:
Must have itch
Plus 3 or more of the following:
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History of involvement in skin creases
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Personal history of asthma or hayfever (or history of atopic disease in 1st degree relative if child is under 4 years of age)
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A history of dry skin in the last year
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Onset under the age of 2 years (not used if child is under 4 years)
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Visible flexural eczema
Assessment tools
Patient assessment should be undertaken by either a medical officer or an eczema nurse consultant/ practitioner to grade the degree of eczema severity (mild, moderate or severe) and the presence or absence of infection. Use SCORAD (scoring atopic dermatitis) index calculator for assessment.
| Eczema Grading | Mild | Moderate | Severe |
| Subjective SCORAD | <25 | 25-50 | >50 |
| Objective SCORAD | <15 | 15-40 | >40 |
Management
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Wet dressings
Cool compresses
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Eczema Treatments fall into two categories
1. Every day treatments (these treatments are ongoing regardless of the presence or absence of eczema)
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Avoiding environmental aggravators; heat, prickly/rough material, dryness of the skin
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Moisturiser
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Bath oil
2. Flaring treatments these treatments should be used as soon as there is a flare (an acute deterioration), such as increasing erythema and itch, and weaned when the symptoms are controlled.
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Topical steroids
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Tar creams for lichenification
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Antibiotics or antivirals if secondary infected
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Wet dressings (apply within 2 days of starting the topical steroids if the eczema has NOT cleared)
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Cool compresses (for immediate relief of itch)
All patients should have an Eczema Treatment Plan completed before they go home. To complete an Eczema Treatment Plan .
Infected Eczema
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Secondary bacterial infection Secondary herpes simplex 1 infection
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Secondary bacterial infection of eczema is a common complication, it should be suspected if there is crusting, weeping, erythema, cracks, frank pus or multiple excoriations and increased itch suggest bacterial infection. The usual organism is Staphylococcus aureus.
Secondary herpes simplex 1 infection is characterised by a sudden onset of grouped, small white or clear fluid filled vesicles, satellite or "punch out" lesions, pustules, and erosions. It is often tender, painful and itchy.
Management of Infected Eczema
The principles of managing infected eczema are:
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Removing the crusts
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Bacterial infections:
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Oral antibiotics
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IV antibiotics for children that are unwell due to the infection
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Herpes simplex virus 1 infected eczema:
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Oral Aciclovir
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IV aciclovir for severe infections, unwell and febrile patients and threatened eye involvement
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NOTE: most patients with viral infected eczema, invariably also have a bacterial skin infection as well. Assess for a bacterial infection and begin antibiotics as instructed above.
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Possible Investigations
Skin swabs:
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Bacterial infections:
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Bacterial skin swabs should be taken from every patient admitted to the medical wards for atopic or discoid eczema from an open, excoriated or crusted eczema lesion to determine bacteria and medication sensitivities.
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Skin swabs should be taken from an infected eczema lesion if multi resistant staphylococcus aureus is suspected or to verify a bacterial infection for all patients attending the RCH Outpatient Department.
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Patients and parents nasal swabs will ONLY be taken for recurrent infections and boils.
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Bacterial or viral swabs may be taken if the diagnosis needs to be verified. Refer to RCH policy on specimen collection
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Herpes Simplex Virus (HSV) swab (in viral medium) to be taken for herpes simplex virus verification.
(Refer to the RCH pathology guideline and ENP guidelines, for the correct process of taking skin swabs)
Allergy Skin Prick Testing (SPT) is indicated if:
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Child had history of flushing, itch, urticaria or general flare of the eczema after ingestion of food
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Itchy child (<12 months) with moderate to severe eczema and not improving with treatment
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Child compliant with adequate treatment regime for greater than 6 weeks with no improvement in eczema
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Eczema lesions are in the periorbital and exposed areas such as arms and legs, may indicate environmental allergy (pollen, dust mite)
Refer to immunologist, allergist or dermatologist for (SPT) and a dietician if food allergies are proven on SPT or RAST test.
Referrals
For further assistance:
| Outpatient and Eczema Workshop appointments | Outpatient department | 9345-6680 |
| Allergy testing and advice | Immunology or Allergy Department | 9345-5733 |
| Family is unable to apply treatment at home |
Home and community care (HACC)- RCH only Royal District Nursing Service |
9345-5695 1300 334 455 |
Follow up
| Inpatient | Outpatient Clinic | 2 weeks post discharge |
| Mild eczema | General Practitioner | |
| Moderate eczema | Outpatient Clinic | two to four weeks, if improved to mild then discharge to General Practitioner |
| Severe eczema | Outpatient Clinic | one to two weeks, then as per mild and moderate |
| Eczema Workshop | Outpatient Clinic | 2- 4 weeks post discharge, then as per mild to severe |
For further assistance the Dermatology Registrars and Nurse Practitioners can be paged via switchboard.
Parent information
Summary points for parents:
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Avoid environmental aggravators- Over heating, rough prickly materials, regular and ongoing use of emollients
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Follow and institute the treatment plan for excellent management and eczema improvement
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Begin flaring treatment as soon as the flare begins and cease flaring treatment until needed again
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Wet dressings are essential in controlling a flare and promoting sleep and should be applied if the other treatments have not cleared the eczema within 24- 48 hours
See parent resources below
Resources
For clinical staff:
For parents:
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Eczema video (available to purchase from the Equipment Distribution Centre)
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Wet Dressing poster (PDF 165KB)
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Equipment Distribution Centre, RCH. For non-prescription treatment purchases at a reduced cost.
Evidence Table
Eczema Management Evidence Table