Clinical Guidelines (Nursing)

Eczema management

  •  RCH: Consider Criteria Led Discharge

    Note: This guideline is currently under review. 


    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.

    Following this link to create a personalised  Eczema Treatment Plan.


    The UK Diagnostic Criteria for atopic eczema are:

    Must have itch

    Plus 3 or more of the following:

    • History of involvement in skin creases
    • Personal history of asthma or hayfever (or history of atopic disease in 1st degree relative if child is under 4 years of age)
    • A history of dry skin in the last year
    • Onset under the age of 2 years (not used if child is under 4 years)
    • Visible flexural eczema
    Erythema: redness of the skin
    eczema - erythema 2
    Discoid eczema: disc shaped, clearly demarcated eczematous patches to limbs and trunk.
    eczema - discoid 1
    eczema - discoid 2

    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 to calculate the severity score.

     Eczema Grading Mild Moderate Severe
    Subjective SCORAD  <25  25-50   >50
    Objective SCORAD  <15 15-40 >40


    Eczema Treatments fall into two categories

    1. Every day treatments and avoidance of triggers (these treatments are ongoing regardless of the presence or absence of eczema)

    • Avoiding environmental aggravators
      • Heat, (clothes, heaters, hot cars, classrooms, hot baths, blankets)
      • Prickly/rough material (wool, sandpits, tags)
      • Dryness of the skin
      • Regular moisturiser; top to toe at least twice a day even if the skin is clear of eczema. Do not double dip in the tub.
    • Daily cool bath; adding salt, bleach 4% (sodium hypochlorite 4%) for chronic, infected eczema (or as recommended by a health professional) and bath oil. Face and head should also be wet and the skin should NOT be rinsed.
    • Consider Vitamin D oral supplementation

    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.

    • Topical steroids/anti inflammatories (generally weaker for the face (e.g.hydrocortisone 1% (mild facial eczema), pimecrolimus(elidel cream) (moderate facial eczema) and stronger for the body e.g. advantan or elocon)
    • Tar creams for lichenification
    • Antibiotics or antivirals for  secondary infected. Usually orally however intravenous for severe infected eczema and when septic.
    • Intranasal bactroban if nasal swabs are positive for Staphylococcus Aureus.
    • Wet dressings (apply as soon as possible for severe eczema. For moderate eczema apply within 1-2 days of starting the topical steroids if the eczema has NOT cleared) 
    • There are 2 types of wet dressings that can be applied. Either can be recommended and cost the same amount. 
    • The Wet dressing regime is as follows;
      • Severe eczema
        • QID for 3 days only (Admission or HITH may be referred to assist this acute phase)
        • Then bd for 1 week
        • Then nightly until the eczema is clear and then recommence nightly if flaring.
      • Moderate eczema
        • Bd for 4 days
        • Nightly until the eczema is clear and then recommence nightly if flaring
      • Mild eczema
        • Nightly if needed until clear and then recommence nightly if flaring.
    • Cool compressing  (for immediate relief of itch)
      • Apply to itchy areas for 5 -10 minutes, apply a moisturizer post compressing
      • These are also the wet dressing for the face, and are best applied while awake and when feeding

    All patients should have an Eczema Treatment Plan completed before they go home. To complete an Eczema Treatment Plan.

    Wet dressings
    eczema - wet dresssing 2
    Cool compresses
    eczema - cold compress

    Infected eczema

    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.

    Secondary bacterial infection
    eczema - infected
    Secondary herpes simplex 1 infection
    eczema - infected foot

    Management of infected eczema

    The principles of managing infected eczema are:

    • Removing the crusts – cool compressing or soaking in the bath
    • Cortisone can be applied over open skin and presence of infection, however rove the crusts and weeping FIRSTLY.
    • Bacterial infections:
      • Oral antibiotics (cephalexin or flucloxacillin)
      • IV antibiotics for children that are unwell due to the skin infection
      • Add White King bleach (4%) to the cool bath water (29 – 30 degrees). The dilution should be 12 mls per 10 litres of water. The scalp and face should also be washed whilst bathing. Bleach can be added to the bath every day
      • Pool salt can be added. The dilution is 100 grams per 10 litres of water
      • Herpes simplex virus 1 infected eczema: for best response start within 48 hours of onset of symptoms; little benefit if treatment is delayed beyond 72 hours unless patient is immunocompromised or has progressive clinical state Oral aciclovir
      • IV aciclovir for severe infections, unwell and febrile patients and threatened eye involvement (refer to opthamology ASAP for eye involvement)
    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.

    Possible investigations

    Skin swabs:
    • Bacterial infections:
      • 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.
      • 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.
      • Patients and parents nasal swabs will ONLY be taken for recurrent infections and boils or suspected nasal carriage.
    • Bacterial or viral swabs may be taken if the diagnosis needs to be verified. Refer to RCH policy on specimen collection
    • Herpes Simplex Virus (HSV) swab (in viral medium) to be taken for herpes simplex virus verification.

    (Allergy Skin Prick Testing (SPT) is indicated if:

    • Child had history of flushing, itch, urticaria or general flare of the eczema after ingestion of food
    • Itchy child (<12 months) with moderate to severe eczema and not improving with treatment
    • Child compliant with adequate treatment regime for greater than 6 weeks with no improvement in eczema
    • 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.


    For further assistance:

    Eczema Workshop appointments Eczema Workshop Clerk 9345-4691 (Mon-Fri)
    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


    1300 334 455

    Community Eczema Program/Workshop. Clinics are located in Collingwood, Kensington and Broadmeadows. Patients are seen by a nurse consultant within 14 calendar days.

    Click here for referral form

    HARP 9345-5972
    Outpatient enquiries   Specialist Clinics 9345-6180 (Mon-Fri)

    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:

    • Avoid environmental aggravators- Over heating, rough prickly materials, regular and ongoing use of emollients
    • Follow and institute the treatment plan for excellent management and eczema improvement
    • Begin flaring treatment as soon as the flare begins and cease flaring treatment until needed again
    • 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

    Eczema resources

    For clinical staff:

    Eczema girl green logo 100px

    For parents:

         Kids Health Information  

    Evidence table

    Eczema Management Evidence Table


    Please remember to read the disclaimer.

    The development of this nursing guideline was coordinated by Emma King, Nurse Practitioner, Dermatology Department, and approved by the Nursing Clinical Effectiveness Committee. Updated May 2013.