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Primary Care Liaison

Eczema - pre-referral guideline

  • The following pre-referral guideline covers Atopic dermatitis, Nummular dermatitis and Infected eczema for children of all ages.

    When to refer

    Immediate referral to the Emergency Department if suspected viral infection is very widespread, occurring in neonate, involving the eyes or associated with fever.

    Dermatology

    • Diagnosis is in question.
    • Lack of satisfactory response to treatment after 6 weeks. (see below)
    • Patient to bring pathology results and documentation of management.
    • SCORAD > 30.
    • Recurrent infections (viral or bacterial).

    Allergy and immunology

    • All babies under 12 months with suspected food allergy.
    • Toddlers and children with severe eczema (SCORAD), known or suspected food and/or environmental allergies.

    Initial work-up

    History

    • General history including failure to thrive.
    • Duration and history of eczema.
    • Possible trigger factors.
    • Family history of atopy.
    • Previous consultations.
    • Past and present treatments used and their effectiveness.
    • The effect of itch on their sleeping pattern.
    • Known allergies, reactions and any formal allergy testing.
    • Other illnesses.
    • Current diet, food eliminated in the past and the effect of this.
    • Compliance with treatment.
    • Social circumstances/ effect on family.
    • Assessment of SCORAD
    Eczema Grading Mild Moderate Severe
    Subjective SCORAD <25 25-50 >50
    Objective SCORAD <15 15-40 >40
    • Bacterial or viral skin swab (when infection is indicated).
    • Nasal skin swab if infection is ongoing.
    • Review of application/ treatment.

    Recommended pre-referral treatment

    Everyday treatment

    • Family education on the nature of the disease.
    • Do not use soap 
    • Use a bath oil or wash. Use QV, Hamiltons, Dermaveen, Avene or Cetaphil products.
    • Bath patient at least once daily < 29C.
    • Pat skin dry after bath and apply cream/ointment to moist skin.
    • Moisturise all over up to 4 times a day - using either Dermeze, Hydraderm, Aqueous cream, QV cream, QV intensive, Cetaphil, Avene or Dermaveen lotion.
    • Educate family on the environmental aggravators of eczema, including the effect of heat (overdressing, heaters, hot baths), prickle (wool, tags on clothing, rough fabrics) and dryness (soaps, heating).

    Flaring treatment

    • Topical corticosteroids - when skin is red or itchy.
      • Face - mild steroid ie. hydrocortisone 1% ointment twice a day, or an anti-inflammatory cream ie. pimecrolimus cream twice a day.
      • Body and scalp - may use mometasone furate 0.1% ointment or methylprednisolone aceponate 0.1% ointment once a day.
    • Prescriptions can be written for multiple tubes of corticosteroid to be given at once (call PBS). Prescribe what the child needs in one week then multiply by four to cover the month.
    • Wet dressings if corticosteroids have not cleared the eczema in 48 hours,or if the child is waking during the night because of the itch. See: Wet dressings
    • Cool compressing for immediate relief of itch.
    • Crusts must be removed. To remove crusts, soak in the bath for 20 minutes and then wipe away. Topical treatments can then be started.
    • Antibiotics - when bacterial infection is indicated.
      • 10 day course of oral antibiotics ie. cephalexin or flucloxacillin, if not contraindicated.
      • Avoid topical antibiotic preparations (eg. Bactroban).
    • Antiseptic bath oils may be used. Exercise extreme caution as they may cause chemical burns.
    • Antivirals - when viral infection is indicated.
      • 10 day course of oral Acyclovir.
    • Continue everyday treatment.
    • Antihistamines.
      • Sedating antihistamines are not recommended for children under 2 years of age.
      • Use nightly for 1-2 weeks (for children over 2 years of age) to aid with sleep pattern.
    • If food allergies are suspected, parents should keep a food diary and record flare-ups, detailing ingestion of food and onset of reaction.

    Contact information

    Clinical advice

     

    Department of Dermatology Outpatients:

    (03) 9345 6180

    Department of Allergy and Immunology:

    (03) 9345 5701

    RCH Emergency Department:

    (03) 9345 6477

    Resources

    References

    Paediatric Handbook online(2009) Eighth Edition.Blackwell Publishing. By the staff of the Royal Children's Hospital, Melbourne, Australia.

    Guideline developed by the RCH Department of Dermatology. First published Jan 2008.  Last updated in November 2009.


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