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Atopic eczema in children
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Introduction
This pathway covers the management of atopic eczema in children from birth up to the age of 12 years
Atopic eczema (atopic dermatitis) is a chronic inflammatory itchy skin condition that usually develops in early childhood and follows a remitting and relapsing course. It often has a genetic component that leads to the breakdown of the skin barrier. This makes the skin susceptible to trigger factors, including irritants and allergens, which can make the eczema worse. Although atopic eczema is not often thought of as a serious medical condition, it can have a significant impact on quality of life. This guideline covers the management of atopic eczema in children from birth up to the age of 12 years, and provides guidance on diagnosis and assessment, management, and providing information and education for children and their parents and carers.
Source guidance
The NICE guidance that was used to create the pathway.
Atopic eczema in children. NICE clinical guideline 57 (2007)
Tacrolimus and pimecrolimus for atopic eczema. NICE technology appraisal guidance 82 (2004)
Frequency of application of topical corticosteroids for atopic eczema. NICE technology appraisal guidance 81 (2004)
Quality standards
Quality statements
Effective interventions library
Successful effective interventions library details
Implementation
Commissioning
These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
Education and learning
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.
Service improvement and audit
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
Pathway information
Information for the public
NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.
Updates to this pathway
8 March 2013 Minor maintenance updates.
Supporting information
Stepped care: treatment options
Mild | Moderate | Severe | |
|---|---|---|---|
Emollients | Emollients | Emollients | |
Mild potency topical corticosteroids | Moderate potency topical corticosteroids | Potent topical corticosteroids | |
Topical calcineurin inhibitors | Topical calcineurin inhibitors | ||
Bandages and dressings | Bandages and dressings | ||
Phototherapy | |||
Systemic therapy | |||
Glossary
Child of 12 or under presents with an itchy skin condition
Child of 12 or under presents with an itchy skin condition
Diagnosis
Diagnosis
Diagnosis
Diagnose atopic eczema when a child has an itchy skin condition plus three or more of the following:
- visible flexural dermatitis involving the skin creases, such as the bends of the elbows or behind the knees (or visible dermatitis on the cheeks and/or extensor areas in children aged 18 months or under)
- personal history of flexural dermatitis (or dermatitis on the cheeks and/or extensor areas in children aged 18 months or under)
- personal history of dry skin in the last 12 months
- personal history of asthma or allergic rhinitis (or history of atopic disease in a first-degree relative of children aged under 4 years)
- onset of signs and symptoms under the age of 2 years (do not use this criterion in children aged under 4 years).
Be aware that in Asian, black Caribbean and black African children, atopic eczema can affect the extensor surfaces rather than the flexures, and discoid (circular) or follicular (around hair follicles) patterns may be more common.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeEducation and information
Education and information
Education and information
Symptoms and epidemiology
Explain the overall severity of a child's atopic eczema to the child and their parents or carers.
Explain that:
- the condition often improves with time, but that not all children will grow out of atopic eczema and it may get worse in teenage or adult life
- children with atopic eczema can often develop asthma and/or allergic rhinitis
- sometimes food allergy is associated with atopic eczema, particularly in very young children
- it is not clear what role factors such as stress, humidity or extremes of temperature have in causing flares of atopic eczema (these factors should be avoided where possible)
- atopic eczema may make the skin darker or lighter temporarily.
Delivering information
Spend time educating children with atopic eczema and their parents or carers about atopic eczema and its treatment. Provide information in verbal and written forms, with practical demonstrations, and cover:
- how much of the treatments to use
- how often to apply treatments
- when and how to step treatment up or down
- how to treat infected atopic eczema.
Reinforce this at every consultation, addressing factors that affect adherence.
When discussing treatment options, tailor the information provided to suit the child's cultural practices relating to skin care (including oiling the skin) and the way they bathe.
Complementary therapies
Discuss complementary therapies with the child and their parents or carers and inform them that:
- the effectiveness and safety of complementary therapies such as homeopathy, herbal medicine, massage and food supplements for the management of atopic eczema have not been adequately assessed in clinical studies
- they should be cautious with the use of herbal medicines in children and be wary of any herbal product that is not labelled in English or does not come with information about safe usageSee Herbal medicines: advice to consumers, available from the MHRA website.
- topical corticosteroids are deliberately added to some herbal products intended for use in children with atopic eczema
- liver toxicity has been associated with the use of some Chinese herbal medicines intended to treat atopic eczema
- they should inform their healthcare professional if they are using or intend to use complementary therapies
- they should keep using emollients as well as any complementary therapies
- regular massage with emollients may improve the atopic eczema.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeWhen to refer
When to refer
When to refer
Referral for specialist dermatological advice
For information on referral for same-day dermatological and ophthalmological advice in children with eczema herpeticum, see herpes infection in this pathway.
Refer urgently (within 2 weeks) for specialist dermatological advice if:
- the atopic eczema is severe and has not responded to optimum topical therapy after 1 week
- treatment of bacterially infected atopic eczema has failed.
Refer for specialist dermatological advice if:
- the diagnosis is, or has become, uncertain
- management has not controlled the atopic eczema satisfactorily based on a subjective assessment by the child or parent/carer (for example, the child is having 1–2 weeks of flares per month or is reacting adversely to many emollients)
- atopic eczema on the face has not responded to appropriate treatment
- the child or parent/carer might benefit from specialist advice on treatment application (for example, bandaging techniques)
- you suspect contact allergic dermatitis (for example, persistent atopic eczema or atopic eczema of the face, eyelids or hands)
- the atopic eczema is causing significant social or psychological problems for the child or parent/carer (for example, sleep disturbance, poor school attendance)
- the atopic eczema is associated with severe and recurrent infections, especially deep abscesses or pneumonia.
Referral for psychological and other specialist advice
Refer for psychological advice children whose atopic eczema has responded to optimum management but for whom the impact on quality of life and psychosocial wellbeing has not improved.
Refer children with moderate or severe atopic eczema and suspected food allergy for specialist investigation and management of the atopic eczema and allergy. (See also the pathway on food allergy in children and young people.)
Refer children with atopic eczema who fail to grow at the expected growth trajectory, as reflected by the UK growth charts, for specialist advice relating to growth.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
Pathway created: August 2012 Last updated: March 2013
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