Eczema

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide staff with the assessment and management of eczema.

Background

Eczema is a dry, itchy chronic inflammatory skin condition, which typically begins in early childhood.

  • Eczema affects 1 in 4 Australian children.
  • Usually starts at less than 12 months of age
  • It follows a remitting and relapsing course
  • Eczema tends to resolve in most children by 5 years.

Assessment

Diagnostic Criteria (adapted from DermNet NZ)1

The diagnosis of eczema is based on patient history and clinical examination. Features to consider when making a diagnosis include:

Essential features:

  • Pruritis
  • Eczema (acute, subacute, chronic)
    • Chronic or relapsing history
    • Typical morphology and age-specific patterns:
    • facial, neck and extensor involvement in infants and children.
    • current or previous flexural lesions at any age.
    • sparing of the groin and axillary regions.
Important features (seen in most cases, adding support to the diagnosis):
  • Early age of onset.
  • Atopy
    • Personal and/or family history.
    • Raised IgE levels.
  • Xerosis (dry skin).

Examination

In order to evaluate the severity of eczema the European Taskforce on Atopic Dermatitis has developed a method allowing consistent assessment by means of a severity index called SCORAD. Alternatively the EASI score can be used which is another validated tool to measure the extent and severity of eczema.

Investigations

Differential diagnoses

  • Psoriasis
  • Histiocytosis
  • Zinc deficiency (if perioral or perianal distribution)
  • Scabies
  • Malaria
  • Tinea
  • Immunodeficiency.

Management

  • Ensure the patient is provided with a Eczema Treatment Plan (PDF 87kb) (complete utilising information as below)
    • All advice given is to be documented in the medical notes. 

Everyday management

  • Avoid aggravating factors such as:
    • Contact irritants (e.g. prickly material, rough clothing, fragrant soaps)
    • Allergens (e.g. dust mites, pollens)
    • Overheating and overdressing.

Bathing

  • Daily bathing in lukewarm water (under five minutes) with dispersible bath oil added to the bath. Bath oil can make the bath slippery when used for older children so caution needs to be taken and alternatively a soap free wash can be used.
    • e.g. QV bath oil, Alpha Keri Oil, Hamilton bath and shower oil
  • Soap and shampoo substitutes should be used. Avoid bubble bath.
    • e.g. QV Gentle Wash, QV Intensive with Ceramides Hydrating Body Wash, Dermeze Moisturising Soap Free Wash, CeraVe Hydrating Cleanser, Cetaphil Gentle Skin Cleanser.

Moisturiser

  • Regular application of emollient will improve the skin barrier and should be done immediately after bathing or showering as this is when emollients are best absorbed.
  • The drier the skin, the thicker the emollient needs to be (e.g. ointment or thick cream) and the more frequent the application. Moisturise the whole body and face once to twice daily. Avoid lotions as they are less hydrating and more likely to sting. 
  • Application of emollient immediately after bathing and twice daily is important to prevent dryness and itching
    • Ointments e.g. Dermeze treatment ointment, QV intensive body moisturiser, Epaderm ointment.
    • Thicker creams e.g. Dermeze treatment cream, QV intensive cream, Epaderm cream.
    • Creams e.g. Sorbolene with 10% Glycerin (tub container not pump), QV cream, CeraVe cream.

Disclaimer: These are examples of suitable emollients for children with eczema. There are many others available. We have no conflict of interest to declare with the products listed above. Some of these formulations are not stocked by the PCH Outpatient Pharmacy. The hospital formulary can be viewed on Formulary 1.

Active eczema (red, itchy, rough areas)

Medicated creams/ointments

  • Topical corticosteroids are the mainstay of treatment.
  • Use on all areas of inflammation and excoriation, not just the worst areas, until complete clearance then stop.
  • Ointment based treatments have an increased moisturising effect and are less likely to sting.
  • Once daily application is usually sufficient.
  • Liberal application is often required.
  • Authority (Streamlined) Prescription is needed when prescribing more than 1 x 15g tube. The majority of children discharged from the ED will require more than a 15g tube (e.g. 4 tubes). Refer to The Pharmaceutical Benefits Scheme website: http://www.pbs.gov.au/pbs/home

The following suggestions are not prescriptive but are a guide for short term use. Suggest medical review if the eczema is not clear after two weeks.

Severity  Scalp  Face  Body/Limbs 
Very mild  Soap free shampoo +/- Hydrocortisone ointment 1 % daily  Hydrocortisone ointment 1% daily   Hydrocortisone ointment 1% daily 
Mild Methylprednisolone aceponate 0.1% Lotion or desonide 0.05% lotion once daily  Methylprednisolone aceponate 0.1% Fatty ointment once daily  Methylprednisolone aceponate 0.1% Fatty Ointment once daily
Moderate  Methylprednisolone aceponate 0.1% Lotion or Mometasone furoate 0.1% Lotion once daily Methylprednisolone aceponate 0.1% Fatty Ointment once daily  Mometasone furoate 0.1% Ointment once daily
Severe  Mometasone furoate 0.1% Lotion once daily  Methylprednisolone aceponate 0.1% Fatty Ointment once daily  Betamethasone diproprionate 0.05% Ointment once daily

Wet dressings

  • Recommended for more severe eczema, especially if the child is itchy or waking at night with itch.
  • Cool the skin which helps to reduce the itch.
  • Assist with penetration of topical corticosteroids for severe inflammation or when the skin is thickened and lichenified.
  • Cool compresses are used as wet dressings to the face
  • Consult with the Dermatology department for guidance regarding application 

Antihistamines

  • Will not help with the itch caused by eczema as the itch is not histamine related.
  • Not usually recommended.
  • Sedating antihistamines may be given to improve the child’s sleep, but it is better to treat to eczema properly.

Infected eczema or skin prone to infection

Dilute bleach baths

  • Anti-infective treatment shown to reduce the incidence of recurrent staphylococcal aureus cutaneous superinfection.
  • Improves the condition of the skin.
  • Usually prescribed twice a week for three months. May be longer if the child has recurrent skin infections. 
  • Dilute bleach bath as per instructions on Health Fact sheet: Diluted bleach baths for children with atopic dermatitis (eczema).

Antibiotics

  • Infected eczema
    • Treatment choice and duration of therapy will depend on the severity of the infection. Consult the Children’s Antimicrobial Management Program (ChAMP) guideline – Skin Soft Tissue and Orthopaedic Infections
  • Infected eczema with herpetic lesions (eczema herpeticum).
    • Commence treatment with aciclovir as per the ChAMP guideline - Aciclovir
  • Localised staphylococcal skin infections
    • Mupirocin 2% ointment or cream topically to crusted areas, twice daily for 5 days.
  • If the child has very severe infected eczema, admit to hospital for intravenous antibiotics or Aciclovir. Intravenous antibiotics for infected eczema are rarely required.

Admission criteria

  • Infected eczema needing intravenous anti-infectives
  • Severe eczema requiring intensive wet wraps in hospital.

Referrals and follow up

Dermatology

  • If moderate to severe eczema for ongoing management.
  • Already on treatment with a topical steroid of moderate to high potency and not responding.
  • Persistent facial eczema requiring frequent topical steroid.
  • Recurrently infected eczema.

The Dermatology Department require the following referral information to assist with triaging referrals:

  • Severity of and duration of condition
  • Type of treatment used in the past and currently. 

Immunology

  • If there is a history of flare ups associated with food
  • History of atopic disease (hay fever, asthma, food allergies).

Managing eczema in children

Click on the image below to access the resource in PDF.

Managing eczema in children guide for clinicians

Bibliography

  1. Purvis D. Guidelines for the diagnosis and assessment of eczema. 2014. Available from DermNet NZ https://dermnetnz.org/topics/guidelines-for-the-diagnosis-and-assessment-of-eczema/ . Accessed May 2020.
  2. Therapeutic Guidelines Ltd. Atopic Dermatitis in Children (December 2019). eTG complete. 2019. https://tgldcdp-tg-org-au.pklibresources.health.wa.gov.au/viewTopic?topicfile=dermatitis#toc_d1e129 Accessed January 2020.
  3. AMH Children’s Dosing Companion (online). Adelaide. Australian Medicines Handbook Pty Ltd; 2020 January. Available from: https://childrens-amh-net-au.pklibresources.health.wa.gov.au/
  4. The Australasian College of Dermatologists Consensus Statement: Topical corticosteroids in paediatric eczema. February 2017. Available from: https://www.dermcoll.edu.au/wp-content/uploads/ACD-Consensus-Statement-Topical-Corticosteroids-and-Eczema-Feb-2017.pdf 
  5. The Pharmaceutical Benefits Scheme: Australian Government Department of Health. Cited 11th February 2020. Available from: http://www.pbs.gov.au/pbs/home

Endorsed by: Head of Department, Emergency Department and Dermatology  Date:  May 2020


 Review date:   May 2023


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