See also

Cellulitis and other bacterial skin infections
Nappy rash

Key points

1. Children with eczema require optimal everyday skin management regardless of the appearance of their skin
2. Topical steroids are safe and effective when used correctly, and are essential to the treatment of eczema flares
3. Caregivers should be educated on how to provide their child with optimal everyday skin management, use topical medicines correctly, avoid triggers and identify signs of an eczema flare or skin infection
4. All children with eczema should be provided with a home eczema management plan, including steps to manage an eczema flare  

Background

• Eczema (atopic dermatitis) is a chronic inflammatory skin disease characterised by dry, itchy skin
• Eczema affects 30% of children, and often develops before 12 months of age. Some children develop lifelong eczema
• The distribution, severity and irritation caused by eczema may acutely worsen, this is termed an eczema flare
• Educating caregivers about eczema and its management is key in reducing the frequency and severity of eczema flares
• Eczema flares are commonly due to inadequate caregiver education on eczema management, and triggers such as skin infection, irritant exposure and heat

Assessment

History

• Onset, pattern and severity of eczema
• In infants <18 months, the cheeks, scalp and extensor surfaces are most often affected
• In older children, eczema commonly presents as flexural dermatitis eg antecubital fossae, popliteal fossae, neck, front of ankles, periorbital area
• Associated symptoms eg reduced sleep, itch, irritability, poor feeding, failure to thrive
• Identified triggers
• Current and previous eczema treatments, including frequency of treatments, volume of creams used, dietary manipulation, complementary treatments
• Previous skin infections eg staph aureus, varicella zoster, herpes simplex virus
• Personal and family history of atopy
• Impact of eczema on child and family quality of life eg number of days of missed school/work, number of hospital admissions
• Poor growth, persistent diarrhoea and/or recurrent infections (consider immunodeficiencies, micronutrient deficiency)
• New itchy rash affecting multiple family members (consider scabies)

Examination

The type and frequency of eczema treatments depends on eczema severity and the presence/absence of infection

Eczema severity

Scoring tools can be used to obtain an objective measure of severity and response to treatment, Eczema Area and Severity Index (EASI) or impact on quality of life Children’s Dermatology Life Quality Index (CDLQI)

Infected eczema

• Cutaneous features include increasing itch, crusted, vesicular, satellite, pustular, erosive, tender, scabbed or weeping lesions on eczematous skin
• Systemic features include fever and malaise
  
  

Eczema bacterial infection Itchy yellowish crusts, weeping, pustules, folliculitis	Eczema herpeticum Painful clustered blisters, punched-out erosions	Eczema coxsackium Vesiculobullous rash with brownish discolouration, satellite lesions surrounding areas of dermatitis

Discoid (nummular) eczema

• A variant type of eczema characterised by coin-shaped, pruritic, inflamed plaques and multiple erythematous papules. Generally develops in later childhood, and is more common in people with dark skin and males
• Associated with increased persistence and treatment resistance, often requiring extended treatment courses with potent steroids. Differential diagnoses include psoriasis, tinea corporis and impetigo. Bacterial and fungal cultures may be useful to clarify the diagnosis
  
  
  

Management

Investigations

• Tests are not usually required
• If there are concerns of severe flare (eg requiring hospitalisation), recurrent skin infections or an infection that does not respond to treatment, skin swabs (bacterial and/or viral) of the lesions may be useful to direct antimicrobial therapy

Treatment

There is no cure for eczema, but it can be well controlled with optimal everyday skin management and correct treatment of eczema flares
All children with eczema should be provided with a home eczema management plan and a demonstration of how to correctly apply topical treatments

Eczema management

Optimal everyday skin management

Moisturisers

• Apply moisturisers generously top-to-toe twice per day, including after bathing
• Reapply if skin feels dry, after hand washing or face wiping
• A thick, plain moisturising cream, with high oil and low water content should be used
• Avoid moisturisers containing fragrance, alcohol, sodium lauryl sulfate, plant or food products (eg cow or goat milk, vegetable, nut or olive oils) as these may disrupt the skin barrier and sensitise the skin
• Avoid contaminating the moisturiser with bacteria from the hands. Use a spatula or spoon to remove cream from tub and place it onto clean paper. Moisturiser from the paper can then be applied by hand to the child’s skin

Bathing

• Daily bathing (where water quality/access allows) aids to reduce the bacterial skin load and reduce the risk of infection
• Baths and showers should be kept luke-warm (<31°C)
• A capful of bath oil may be added to bath water, advise parents this increases risk of child slipping, and direct supervision is always required
• Do not use soap or shampoo. Use soap-free skin cleansers that will not irritate the skin
• Avoid sharing towels between family members
• Avoid wash/cleanser products or hair washing products that contain methylisothiazolinone (MI) or methylchloroisothiazolinone (MCI) and nappy wipes that contain benzalkonium chloride, as these can cause contact dermatitis

General considerations

• Food allergies: Allergy testing is usually not required. Restrictive diets are usually not helpful, and parents should seek advice from a dermatologist or general paediatrician before eliminating foods from the diet
• Antihistamines: Non-sedating antihistamines do not improve eczema itch, but may be considered if there is concomitant urticaria or allergic rhinitis

Common reasons for eczema treatments not being effective include:

• Inadequate education regarding eczema and the correct use of eczema treatments
• Inadequate application of moisturisers, topical steroids and/or wet dressings 
• Ongoing exposure to eczema triggers
• Delayed use of eczema flare treatments eg topical steroids and wet dressings
• Inability to identify and treat skin infections
• MRSA bacterial infection

Minimising common eczema flare triggers

Eczema flare management

Steroids

• Topical steroids (see additional resources below) are required once or twice daily until the skin is completely clear to reduce skin inflammation. They can be applied to broken and infected skin
• There is no requirement to use steroids ‘sparingly’ or for regular breaks from steroids during treatment for eczema flares. Steroids should be applied generously followed by moisturiser. Steroid cream dosage for application be calculated using the " Fingertip Unit" method

• Topical steroids do not cause atrophy, hypopigmentation, hypertrichosis, osteoporosis, purpura or telangiectasia when used as per guidelines. Rare complications such as striae, adrenal suppression and ophthalmological disease have been reported with prolonged and excessive use of potent topical steroids
• Mild to moderate facial eczema should be treated with low potency steroids to avoid chemical skin irritation. Topical pimecrolimus is a non-steroid alternative that may be used as a second line treatment for moderate eczema in sensitive areas such the face, eyelids and groin

Moisturisers

• Continue moisturiser at least twice a day, apply to wet skin after bathing and reapply whenever skin feels dry
•  Apply the moisturiser on top of other topical medicines such as steroids

Wet dressings

• Wet dressings assist to return moisture to the skin, protect from infection and further trauma, and help to reduce irritation and itch
• Dressings should be applied with every flare 1-4 times daily for at least 3 days. More frequent dressings and/or longer treatment may be required in severe eczema
• May be used in eczematous skin infections, in addition to antimicrobial treatment  
• Parents must be educated on how to correctly make and apply wet dressings
• Cool compresses (cloth or towel soaked in water and/or bath oil) can used on the face to provide immediate relief of itch
• Hospital in the home services may be available in some areas to assist and educate caregivers

Bathing

• Bleach baths can be used daily with every flare to reduce the bacterial skin load
• The child’s face and head should be wet during the bath, but not submerged
• Do not rinse after bathing

Eczematous skin infections

Broken eczematous skin has a high-risk of bacterial and/or viral skin infections

Bacterial infections

• Common causative organisms include Staphylococcus aureus (consider MRSA in high-risk groups or if not responding to first-line antibiotics) and Streptococcus pyogenes
• Remove crusted lesions by wiping them gently with a cloth whilst soaking in the bath. Only apply topical steroids and moisturisers after the crusts are removed
• Treat with antibiotics. Children who have systemic features or severe infections may require admission and intravenous antibiotics

Viral infections

• Common causes include herpes simplex, coxsackievirus, molluscum contagiosum and varicella zoster viruses
• Often co-exist with bacterial infection, consider if infected eczema is not responding to antibiotic management
• Herpes simplex infection (eczema herpeticum) requires prompt initiation of antiviral treatment. Intravenous antiviral treatment may be required in severe infections. Urgent Ophthalmology review is required if the infection affects the periorbital area

Recurrent infections

• Consider patient and family Staphylococcus aureus decolonisation
• Antiseptic preparations may reduce skin bacterial load eg bleach baths, triclosan skin cleanser, chlorhexidine skin wash

Consider consultation with local paediatric team when

• Eczema herpeticum or severe bacterial eczematous skin infections
• Moderate or severe eczema not responding to treatment despite compliance with correct treatment for 2 weeks or more
• Concern that the child’s carers are not able to provide appropriate eczema treatments and are unable to access outpatient supports
• Severe eczema in a child <12 months old
• Poor feeding, poor sleep, failure to thrive
• Suspicion of systemic disease eg immunodeficiency or micronutrient deficiency
• Suspicion of concurrent severe allergies eg recurrent urticarial, systemic flushing, periorbital eczema, eczema limited to exposed skin - limbs

Consider consultation with local dermatology team when

• Chronic eczema not controlled with optimised topical therapies and everyday skin management, for consideration of systemic therapies

Additional notes

• ASCIA Eczema Action Plan
• ASCIA Eczema e learning
• Eczema Area and Severity Index (EASI)
• Skin Deep - Eczema photo gallery in a range of skin tones  

Parent information & resources

• RCH Kids Health Information: Eczema
• RCH Kids Health Information: Bleach baths
• RCH Knowing your child’s eczema – parent resources page (English, Vietnamese, Mandarin)
• RCH Eczema triggers identification questionnaire
• The Eczema Association of Australasia
• ASCIA Eczema and food allergy
• Nip allergies in the bub - Eczema  
• AMH Fingertip units

Additional resources

Medication Information

Provide children with prescriptions for multiple quantities and repeats (PBS authority where applicable) of each medication 

Last updated January 2024