Eczema

Disclaimer

These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. 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.

 

Introduction

Eczema (atopic dermatitis) is a very common skin condition that often begins in infancy or early childhood. Most affected children develop eczema before the age of two years, and it usually improves by the age of five. There is often no single trigger for an eczema flare.

Food allergy is more common in children with eczema who also have a family history of allergic disease. Managing eczema well in infants may reduce their chance of developing food allergy. Allergy testing is not routinely recommended for children with eczema and food elimination diets are also not routinely recommended. Skin prick testing and food challenges are usually only helpful in severe cases of eczema where there has been a poor response to first-line treatment or clinical history of allergic reaction.

Unless there is a known or suspected allergy, all infants including those with eczema, should be given a wide range of foods including smooth peanut paste, cooked egg, dairy and wheat products in their first year of life.

Pre-referral management

Please refer to:

The following suggestions are not prescriptive, but are a guide for short term use.

GP review is advised after two weeks to assess the child's response to treatment.

 Severity  Scalp Face Body/limbs
 Very mild  Soap free shampoo +/- Hydrocortisone 1% ointment twice daily  Hydrocortisone 1% ointment twice daily  Hydrocortisone 1% ointment twice 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 dipropionate 0.05% ointment once daily
 Hydrocortisone: all ages1, Methylprednisolone aceponate: ≥ 4 months1, Desonide / Mometasone furoate: ≥ 1 month1, Betamethasone dipropionate: ≥4 months2
  • Skin swabs for bacterial or viral infections if required.
  • Swabs of potential staphylococcal aureus carriage sites should be considered in patients with recurrent episodes of infected eczema or skin infection. Suggested swab sites are nose, throat, axilla and wound. Refer to ChAMP Monographs and Guidelines for Staphylococcus aureus decolonisation-paediatric.

Common reasons for suboptimal management:

  • Inadequate strength, amount and formulation of topical corticosteroid prescribed.
    • determined by child’s age, eczema severity and affected site(s)
  • Advising corticosteroid use for a certain number of days rather than using daily until the eczema has completely cleared i.e. skin feels smooth.
  • If treatment is ceased before the skin has returned to normal, it is more likely to flare again quickly.

When to refer

Up to 16 years of age; and has any of the following criteria, refer to Dermatology Department:

  • Moderate to severe eczema for ongoing management.
  • Already on optimal treatment with a topical corticosteroid of moderate to high potency and not responding as expected.
  • Persistent or frequent facial eczema requiring frequent use of topical corticosteroid.
  • Recurrent episodes of infected eczema.
  • Any patient with eczema or significant concern to the parent or GP that does not meet the above criteria.

Refer to Immunology Department if:

  • There is a history of flare ups associated with food.
  • If your concern relates to a suspected food allergy and/or environmental allergy.

How to refer

  • Routine non-urgent referrals from a GP or a Consultant are made via the Central Referral Service
  • Routine non-urgent referrals from a nurse practitioner, non-medical referrers or private hospitals are made via the PCH Referral Office
  • Urgent referrals (less than seven days) are made via the PCH Referral Office. Please call PCH Switch on 6456 2222 to discuss with the Dermatology registrar. 

Essential information to include in your referral

  • Severity and duration of eczema.
  • Type of treatment used in the past and currently.
  • If the patient has failed to respond to optimal first-line treatment.

References

  1. Australian Medicines Handbook Children’s Dosing Companion Online [internet] Australia: Australian Medicines Handbook Pty. Ltd.; 2022.
  2. Weston, Stephanie (Consultant Dermatologist), Expert Opinion, Perth Children’s Hospital, February 2022.

Useful resources

  1. Eczema - ED Guideline
  2. Managing eczema in children: A guide for clinicians
  3. Australian College of Dermatologists Consensus Statement Topical Corticosteroids in Paediatric Eczema
  4. Eczema in Children - HealthPathways Western Australia
  5. Staphylococcus aureus Decolonisation - ChAMP Guideline
  6. Staphylococcus aureus treatment - Health Fact sheet


Reviewer/Team:   Dr Stephanie Weston and Jemma Weidinger – Dermatology Department Last reviewed: Feb 2022


Review date: Feb 2025
Endorsed by:   Dermatology department Date:  Feb 2022


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