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 Emergency Department (ED) staff with the assessment and management of eczema.

Background

Eczema is a dry, itchy chronic inflammatory skin condition, which typically begins in early childhood.¹

• 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 the time they start school.

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

The Eczema Area Severity Index (EASI) score can be used to measure the extent and severity of eczema. This can be used as a guide to clinical features, but you are not expected to undertake these scores as part of an examination in ED.

• EASI calculator (Eczema Area and Severity Index).

Investigations

• Skin swabs for bacterial or viral infections if required.
• Swabs of potential Staphylococcus aureus carriage sites should be considered in patients with recurrent skin infection. Suggested sites are nose, throat, axilla and wound.
• Refer to MRSA and MSSA Guideline for staphylococcal decolonisation (paediatric) - ChAMP Guideline.

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) - Health Fact sheet (complete utilising information as below)
  
  • All advice given is to be documented in the medical notes. 

Everyday management

• Avoid overheating and overdressing.
• Keep the nails short to avoid damage to the skin from scratching.
• Avoid irritants where possible. Rinse after swimming in chlorine or salt water. Minimise skin contact with grass, sand and carpet.

Bathing

• Daily bath or shower (short, less than 5 minutes using lukewarm water with bath oil or soap-free wash; avoid soap and bubble baths).
• 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 & 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 moisturiser will improve the skin barrier and should be done immediately after bathing or showering as this is when moisturisers are best absorbed.
• Moisturise the whole body including face once to twice daily. The drier the skin, the thicker the cream needs to be. Use a cream or ointment rather than a lotion as it is more moisturising and less likely to sting. Avoid skin products containing food derived proteins (e.g. goat milk, nut oils) and fragrance.
  • Ointments e.g. Dermeze Treatment Ointment®, QV Dermcare Sting-Free Ointment®, Epaderm Ointment®.
  • Thicker creams e.g. Dermeze Treatment Cream®, QV Intensive Cream®, Epaderm Cream®.
  • Creams e.g. Sorbolene cream with 10% Glycerin (tub container not a pump), QV Cream®, CeraVe Cream®, Dermeze cream®.

Disclaimer: These are examples of suitable moisturisers 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)

Topical steroids

• Topical steroids are safe and effective in the treatment of eczema when used as prescribed. Ointments are preferred in most cases as they are more effective, more moisturising and less likely to sting than creams. Ointments can be used on the scalp if lotions sting.
• Apply topical steroid liberally to cover all eczema affected areas (not just to the worst areas) until the skin feels normal.
• Post-inflammatory hypo or hyperpigmentation is a common result of eczema and usually self resolves.
• Darker skin pigment can be challenging to assess, and eczema severity is often under-recognised, leading to more severe and persistent symptoms.
• Topical steroids are usually packed in small tubes. Patients will often require more than a single tube. Ensure the number of tubes prescribed is adequate for liberal application by providing authority scripts.

Topical calcineurin inhibitors for troublesome facial eczema

• Topical calcineurin inhibitors are typically used for children requiring frequent and prolonged application of methylprednisolone aceponate on the face. Pimecrolimus 1% cream is approved for children ≥ 3 months with mild to moderate facial eczema and is applied twice daily.²
• Tacrolimus 0.03% ointment (not available commercially, must be compounded), is approved for children ≥ 2 years with moderate to severe facial eczema and is applied to affected areas once to twice daily as directed.³
• If using these agents, consider discussion with and/or referral to the Dermatology Team.

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 steroids 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.
  
  • If unavailable refer to Caring for your child’s eczema - Health Fact sheet for instructions on use.

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 actively treat the eczema promptly.

Infected Eczema or skin prone to infection

Dilute bleach baths^4,5

• Anti-infective treatment shown to reduce the incidence of recurrent Staphylococcus 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 Caring for your child’s eczema - Health Fact sheet.

Antibiotics and Antivirals

• 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 and Soft Tissue Infections – Paediatric Empiric Guidelines - ChAMP.
• Infected eczema with herpetic lesions (eczema herpeticum):
  • Commence treatment with Aciclovir. Refer to Aciclovir Monograph - ChAMP guideline.
• Localised staphylococcal skin infections:
  • Mupirocin 2% ointment or cream topically to crusted areas, twice daily for 5 days.⁶
• If the child has very severe infected eczema admit to hospital for intravenous antibiotics or aciclovir. Intravenous antibiotics for infected eczema are rarely required.

Managing eczema in children: A guide for clinicians

Download the guide (PDF)

Admission criteria

• Infected eczema needing intravenous anti-infectives
• Severe eczema requiring intensive wet dressings 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

Download the clinicians' guide to managing ezcema (PDF).

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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