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Criteria Led Discharge
Atopic eczema (AE) or atopic dermatitis (AD) is a chronic, inflammatory, skin condition that is itchy and often dry. It typically begins in early childhood and affects around 30% of children in Australia. This condition can worsen if not treated and cause intractable pruritus, soreness and sleep disturbance and can be complicated by secondary infection. The onset of eczema is commonly before 12 months of age and typically follows a remitting and relapsing course. Many children will "grow out of" eczema. There is no cure for AD, however if treated and managed effectively 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.
To provide evidence-based strategies for the management of AE in order to improve eczema severity and reduce the negative impact on patient and family quality of life.
The UK Diagnostic Criteria for atopic eczema are:
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 or EASI score to calculate the severity score.
Eczema Treatments fall into two categories
These treatments are ongoing regardless of the presence or absence of eczema.
These treatments should be commenced as soon as there is a flare (when the skin is rough - like sandpaper, an increase in redness, itch and acute deterioration), and stopped when the symptoms are controlled and re-started if flaring again. As the eczema is better controlled the need for topical steroids will decrease however a moisturiser should always be applied at least twice daily.Topical steroids and anti-inflammatory creams
Tar creams are used when the skin is lichenified (thickening of the skin) or for discoid eczema. Tar creams should not be applied to the face, groin and flexures. These creams can be applied directly over the steroid creams and under the moisturiser. A suggested compound for a tar cream is 3% LPC in zinc cream (example KenKaytm dual purpose cream).
Medications such as antibiotics or antivirals may be prescribed for treatment of organisms causing secondary infected eczema. Usually oral antibiotics are required however intravenous may be needed for severely infected eczema and sepsis.
If nasal swabs are positive for Staphylococcus aureus intranasal mupirocin ointment can be used twice daily for five days. If skin infections reoccur, consider treating the whole family using Staph decolonisation processes.
Antihistamines are not routinely used for eczema unless it has been triggered by an allergic reaction or insect bites. They do not assist with the eczema itch. Use with caution in children under 12 months of age.
Wet dressings are used for moderate to severe eczema or when the children are waking from the itch. The aim of wet dressing is to have greater penetration of topical moisturisers and to over hydrate the skin, also to sooth, cool and act as a barrier to scratching.If the wet dressings (example Tubifasttm) are not readily available use wet clothes (onesie, leggings/T Shirt) instead. A dry layer of clothing may be applied over this however remove the top layer when dry and if awake. Wet dressings should only be needed for 3-5 nights.
Wet dressings to re-hydrate and calm the skin using Tubifast tm
The Wet dressing/clothes regime is as follows:
Cool compressing for immediate relief of itch
Secondary infection of eczema is a common complication as the skin is not intact and thus more vulnerable to infection. Infection can make eczema worse and more difficult to treat. A common causative bacterium is Staphylococcus aureus which is commonly found on eczema skin. Infection should be suspected if there is crusting, weeping, erythema, cracks, frank pus or multiple excoriations and increased soreness and itching which may suggest bacterial infection. Secondary viral infection caused by herpes simplex virus (HSV) is characterized 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. Other viruses that may cause the eczema to flare are molluscum contagiosum and coxsackie A6 virus (hand foot and mouth disease).
The principles of managing infected eczema are:
NOTE: most patients with viral infected eczema, invariably also have a bacterial skin infection as well. Assess using appropriate skin swabs to identify causative organism.
Urgent Ophthalmology review if the infection is near the eye(s).
For every inpatient admitted for eczema bacterial skin swabs should be taken.
For patients attending the RCH Outpatient Department, a skin swab should be taken from an infected eczema lesion when MRSA is suspected or to verify a bacterial organism
Patient and parent nasal swabs are only required for patients who are experiencing recurrent infections and boils when suspecting ongoing nasal carriage.
Viral swabs may be needed to confirm causative organism, this should be collected from the base of a fresh blister.
In the event of an immediate reaction (such as urticaria and angioedema) to a food and/or severe persistent eczema in a baby, refer for specialist allergy evaluation.
Visit ASCIA for more information:
Refer to immunologist, allergist or dermatologist for Skin Prick Test (SPT) and a dietician if food allergies are proven on SPT or ImmunoCAP IgE test.
All patients should have an Eczema Treatment Plan completed before they go home. To complete an Eczema Treatment Plan.
A medical referral is required for
Home and community care (HACC)- RCH only
Royal District Nursing Service
For further assistance the Dermatology Registrars can be paged via switchboard 9345 5522.
Discuss the everyday treatments – avoidance of environmental triggers - overheating, rough prickly materials, and ensure regular and ongoing use of moisturisers and eczema baths.Give guidance on eczema treatment plan
Encourage the families to undertake the Eczema E learn for education and demonstration of how to apply the topical treatments. Provide adequate prescriptions of topical steroid to cover until the patient is seen by the next professional such as GP, dermatologist, dermatology nurse consultant/practitioner.
parent resources below
Eczema Management Evidence Table
Please remember to
read the disclaimer.
The development of this nursing guideline was coordinated by Emma King, Nurse Practitioner and members of Dermatology Department and Allergy Department, and approved by the Nursing Clinical Effectiveness Committee. Updated June 2021.