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:

Eczema in children - Clinician Assist WA
Managing eczema in children: A guide for clinicians

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

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

Useful resources

Eczema - ED Guideline
Managing eczema in children: A guide for clinicians
Australian College of Dermatologists Consensus Statement Topical Corticosteroids in Paediatric Eczema
Clinician Assist WA
Staphylococcus aureus Decolonisation - ChAMP Guideline
Staphylococcus aureus treatment - Health Fact sheet
Atopic dermatitis skin of colour clinician toolkit

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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