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Eczema

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What is covered

This interactive flowchart covers:
  • the management of atopic eczema in children aged up to 12 years
  • treatments for eczema in adults and young people aged 13 years and over.
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.

Updates

Updates to this interactive flowchart

17 May 2016 ImmunoCAP ISAC 112 and Microtest for multiplex allergen testing (NICE diagnostics guidance 24) added to identify trigger factors.
12 October 2015 Alitretinoin for the treatment of severe chronic hand eczema (NICE technology appraisal guidance 177) and Grenz rays therapy for inflammatory skin conditions (NICE interventional procedures guidance 236) added to treating eczema in people over 12.
4 September 2013 Atopic eczema in under 12s (NICE quality standard 44) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on managing atopic eczema in children up to 12 years, and treating eczema in people aged 13 years and over in an interactive flowchart

What is covered

This interactive flowchart covers:
  • the management of atopic eczema in children aged up to 12 years
  • treatments for eczema in adults and young people aged 13 years and over.
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.

Updates

Updates to this interactive flowchart

17 May 2016 ImmunoCAP ISAC 112 and Microtest for multiplex allergen testing (NICE diagnostics guidance 24) added to identify trigger factors.
12 October 2015 Alitretinoin for the treatment of severe chronic hand eczema (NICE technology appraisal guidance 177) and Grenz rays therapy for inflammatory skin conditions (NICE interventional procedures guidance 236) added to treating eczema in people over 12.
4 September 2013 Atopic eczema in under 12s (NICE quality standard 44) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Alitretinoin for the treatment of severe chronic hand eczema (2009) NICE technology appraisal guidance 177
Tacrolimus and pimecrolimus for atopic eczema (2004) NICE technology appraisal guidance 82
Frequency of application of topical corticosteroids for atopic eczema (2004) NICE technology appraisal guidance 81
Grenz rays therapy for inflammatory skin conditions (2007) NICE interventional procedures guidance 236
Atopic eczema in under 12s (2013) NICE quality standard 44

Quality standards

Atopic eczema in under 12s quality standard

These quality statements are taken from the atopic eczema in under 12s quality standard. The quality standard defines clinical best practice for atopic eczema in under 12s and should be read in full.

Quality statements

Assessment at diagnosis

This quality statement is taken from the atopic eczema in under 12s quality standard. The quality standard defines clinical best practice for atopic eczema in under 12s and should be read in full.

Quality statement

Children with atopic eczema are offered, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.

Rationale

Recording a child's detailed clinical and treatment history as part of the assessment in all healthcare settings is an important step in the management of atopic eczema in children. At the diagnosis stage, assessing potential trigger factors, including irritants and allergens, will lead to better management and potentially lead to a reduction in the severity of the atopic eczema experienced by the child.

Quality measures

Structure
Evidence of local arrangements to ensure that children with atopic eczema are offered, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.
Data source: Local data collection.
Process
The proportion of children with atopic eczema who receive, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.
Numerator: the number of children in the denominator who receive, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.
Denominator: the number of children with newly diagnosed atopic eczema.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place to offer children with atopic eczema, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.
Healthcare practitioners offer children with atopic eczema, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.
Commissioners ensure that they commission services with local arrangements to offer children with atopic eczema, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.

What the quality statement means for patients and carers

Children with atopic eczema are offered an assessment, in which their healthcare professional records their detailed medical and treatment histories and identifies any factors that might trigger their eczema.

Source guidance

Atopic eczema in children (NICE clinical guideline 57), recommendations 1.1.1.1 and 1.4.1.1 (key priority for implementation).

Definitions

Clinical and treatment histories
NICE clinical guideline 57 recommends that healthcare practitioners take detailed clinical and treatment histories at diagnosis to aid management of atopic eczema in children, and that these should include questions about:
  • time of onset, pattern and severity of the atopic eczema
  • response to previous and current treatments
  • possible trigger factors (irritant and allergic)
  • the impact of the atopic eczema on children and their parents or carers and families
  • dietary history including any dietary manipulation
  • growth and development
  • personal and family history of atopic diseases.
Potential trigger factors
NICE clinical guideline 57 recommends that when clinically assessing children with atopic eczema, healthcare practitioners should seek to identify potential trigger factors including irritants, for example soaps and detergents, skin infections and contact, food and inhalant allergens. In addition, the expert opinion of the Topic Expert Group stated that psychological stress can cause flares of atopic eczema, and should be avoided where possible.

Stepped approach to management

This quality statement is taken from the atopic eczema in under 12s quality standard. The quality standard defines clinical best practice for atopic eczema in under 12s and should be read in full.

Quality statement

Children with atopic eczema are offered treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Rationale

Atopic eczema is typically an episodic condition consisting of flares and remissions, though in some children it is continuous. Treatment for atopic eczema should be tailored, with treatments stepped up and down according to the recorded severity of symptoms. Areas of atopic eczema of differing severity can coexist in the same child, and each area should be treated independently. The stepped-care plan involves self-management and adherence to treatment, therefore healthcare practitioners should give children with atopic eczema and their families or carers support and information on when and how to step treatment up or down.

Quality measures

Structure
Evidence of local arrangements to ensure that children with atopic eczema are offered treatment based on recorded eczema severity using the stepped-care plan, supported by education.
Data source: Local data collection.

Process

(a) The proportion of children with atopic eczema who have their eczema severity recorded at each eczema consultation.
Numerator: the number of children in the denominator who have their eczema severity recorded at each eczema consultation.
Denominator: the number of eczema consultations with children with atopic eczema.
Data source: Local data collection.
(b) The proportion of children with atopic eczema who receive treatment based on recorded eczema severity using the stepped-care plan, supported by education.
Numerator: the number of children in the denominator who receive treatment based on recorded eczema severity using the stepped-care plan, supported by education.
Denominator: the number of children with atopic eczema.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place to offer children with atopic eczema treatment based on recorded eczema severity using the stepped-care plan, supported by education.
Healthcare practitioners offer children with atopic eczema treatment based on recorded eczema severity using the stepped-care plan, supported by education.
Commissioners ensure that they commission services with local arrangements to offer children with atopic eczema treatment based on recorded eczema severity using the stepped-care plan, supported by education.

What the quality statement means for patients and carers

Children with atopic eczema are offered treatment using a stepped-care plan (which means that treatments are added or stopped depending on how severe the eczema is) and given advice and information about atopic eczema and its treatment.

Source guidance

Atopic eczema in children (NICE clinical guideline 57), recommendations 1.2.1.1 (key priority for implementation), 1.2.1.3 and 1.5.1.1 (key priority for implementation).

Definitions

Eczema severity
NICE clinical guideline 57 recommends an assessment of the physical severity of atopic eczema and the impact of atopic eczema on quality of life and social wellbeing at each eczema consultation. The guideline defines the physical severity of atopic eczema as follows:
  • Clear: normal skin, no evidence of active atopic eczema
  • Mild: areas of dry skin, infrequent itching (with or without small areas of redness)
  • Moderate: areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening)
  • Severe: widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation).
Stepped approach to management
NICE clinical guideline 57 recommends that healthcare practitioners use a stepped approach to managing atopic eczema in children, which means tailoring the treatment step to the severity of the atopic eczema. Emollients should form the basis of atopic eczema management and should always be used, even when the atopic eczema is clear. Management can then be stepped up or down, according to the severity of symptoms, by adding or withdrawing treatments as follows (phototherapy and systemic therapy should be undertaken only under specialist dermatological supervision by staff who are experienced in dealing with children):
Mild atopic eczema
Moderate atopic eczema
Severe atopic eczema
Emollients
Emollients
Emollients
Mild-potency topical corticosteroids
Moderate-potency topical corticosteroids
Potent topical corticosteroids
Topical calcineurin inhibitors
Topical calcineurin inhibitors
Bandages
Bandages
Phototherapy
Systemic therapy
Healthcare practitioners should review repeat prescriptions of individual products and combinations of products with children with atopic eczema (and their parents or carers) at least once a year to ensure that treatment remains optimal
Supported by education
Education on the use of, and adherence to, treatment is essential to the stepped-care plan approach. NICE clinical guideline 57 recommends that healthcare practitioners offer children with atopic eczema (and their parents or carers) information on how to recognise the symptoms and signs of bacterial infection and also how to recognise and manage flares of atopic eczema according to the stepped-care plan. Healthcare practitioners should spend time educating children with atopic eczema (and their parents or carers) about atopic eczema and its treatment. They should provide information in verbal and written forms, with practical demonstrations, and should cover:
  • how much of the treatments to use
  • how to apply and how often to apply prescribed treatments, including emollients, steroids, calcineurin inhibitors and medicated dressings (bandages)
  • when and how to step treatment up or down
  • how to treat infected atopic eczema.
This should be reinforced at every consultation, addressing factors that affect adherence.

Equality and diversity considerations

Healthcare practitioners should be aware of the potential difficulties of assessing eczema severity in children with darker skin tones.
In recommending skin treatments, healthcare practitioners should be sensitive to the cultural practices of families or carers of children with atopic eczema. For example, if families or carers use olive oil as a skin treatment (which is likely to be harmful to a child's skin) or if they rinse children after bathing (rinsing off emollients), the reasons for using the recommended treatment and applying it correctly should be explained sensitively.

Psychological wellbeing and quality of life

This quality statement is taken from the atopic eczema in under 12s quality standard. The quality standard defines clinical best practice for atopic eczema in under 12s and should be read in full.

Quality statement

Children with atopic eczema have their (and their families') psychological wellbeing and quality of life discussed and recorded at each eczema consultation.

Rationale

Healthcare practitioners should adopt a holistic approach when assessing a child's atopic eczema at each eczema consultation, taking into account the severity of the atopic eczema and the impact on the child's quality of life. Atopic eczema can have a negative psychological effect on children and their families or carers. Discussing and recording the impact of the atopic eczema (even if its physical severity is mild) on psychological and psychosocial wellbeing and quality of life is an essential part of a holistic approach, and can inform treatment strategies.

Quality measures

Structure
Evidence of local arrangements to ensure that children with atopic eczema have their (and their families') psychological wellbeing and quality of life discussed and recorded at each eczema consultation.
Data source: Local data collection.

Process

The proportion of eczema consultations with children with atopic eczema at which their (and their families') psychological wellbeing and quality of life is discussed and recorded.
Numerator: the number of consultations in the denominator at which children's (and their families') psychological wellbeing and quality of life is discussed and recorded.
Denominator: the number of eczema consultations with children with atopic eczema.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that local arrangements are in place for children with atopic eczema and their families to be asked about their psychological wellbeing and quality of life, and for this to be recorded at each eczema consultation.
Healthcare practitioners ensure that children with atopic eczema and their families are asked their psychological wellbeing and quality of life, and that this is recorded at each eczema consultation.
Commissioners ensure that they commission services with local arrangements for children with atopic eczema and their families to be asked about their psychological wellbeing and quality of life, and for this to be recorded at each eczema consultation.

What the quality statement means for patients and carers

Children with atopic eczema and families and/or carers are asked about how they are feeling and how the eczema is affecting their lives on a day-to-day basis, and have this recorded at each eczema consultation.

Source guidance

Atopic eczema in children (NICE clinical guideline 57), recommendations 1.2.1.1 (key priority for implementation), 1.2.1.4 and 1.2.1.5.

Definitions

Psychological wellbeing and quality of life
NICE clinical guideline 57 recommends that healthcare practitioners should adopt a holistic approach when assessing a child's atopic eczema at each consultation. Healthcare practitioners should take account of the child's quality of life, including everyday activities and sleep, and psychosocial wellbeing, as well as the physical severity of their condition. There is not necessarily a direct relationship between the severity of atopic eczema and its impact of quality of life. Even mild atopic eczema can have a negative impact on psychological and psychosocial wellbeing and quality of life.
The guideline defines the impact of atopic eczema on quality of life and psychosocial wellbeing as follows:
  • None: no impact on quality of life
  • Mild: little impact on everyday activities, sleep and psychosocial wellbeing
  • Moderate: moderate impact on everyday activities and psychosocial wellbeing, frequently disturbed sleep
  • Severe: severe limitation of everyday activities and psychosocial functioning, nightly loss of sleep.
The guideline recommends that healthcare practitioners take into account the impact of atopic eczema on parents or carers as well as the child.
In the opinion of the Topic Expert Group, the impact of atopic eczema on families and/or their carers will usually be recorded in the notes of the child who has atopic eczema.

Provision of emollients

This quality statement is taken from the atopic eczema in under 12s quality standard. The quality standard defines clinical best practice for atopic eczema in under 12s and should be read in full.

Quality statement

Children with atopic eczema are prescribed sufficient quantities (250–500 g weekly) from a choice of unperfumed emollients for daily use.

Rationale

Emollients should form the basis of atopic eczema management and should always be used, even when the atopic eczema is clear. Children with atopic eczema should have sufficient quantities of emollients for everyday use. These should be suited to the child's needs and preferences, with alternatives offered if a particular emollient causes irritation or is not acceptable to a child.

Quality measures

Structure
Evidence of local arrangements to prescribe children with atopic eczema sufficient quantities (250–500 g weekly) from a choice of unperfumed emollients for daily use.
Data source: Local data collection.

Process

The proportion of children with atopic eczema who are prescribed sufficient quantities (250–500 g weekly) of unperfumed emollients for daily use.
Numerator: the number of children in the denominator who are prescribed sufficient quantities (250–500 g weekly) of unperfumed emollients for daily use.
Denominator: the number of children with atopic eczema.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that local arrangements are in place to prescribe children with atopic eczema sufficient quantities (250–500 g weekly) from a choice of unperfumed emollients for daily use.
Healthcare practitioners ensure that they prescribe children with atopic eczema sufficient quantities (250–500 g weekly) from a choice of unperfumed emollients for daily use.
Commissioners ensure that they commission services with local arrangements for children with atopic eczema to be prescribed with sufficient prescribed quantities (250–500 g weekly) from a choice of unperfumed emollients for daily use.

What the quality statement means for patients and carers

Children with atopic eczema receive a prescription for enough (between 250 g and 500 g weekly) unperfumed emollient (a special type of skin moisturiser) chosen to best suit their needs and preferences for daily use.

Source guidance

Atopic eczema in children (NICE clinical guideline 57), recommendations 1.5.1.1, 1.5.2.1 (key priorities for implementation) and 1.5.2.2.

Definitions

Unperfumed emollients
NICE clinical guideline 57 recommends that a choice of unperfumed emollients should be offered to children with atopic eczema that is suited to the child's needs and preferences for everyday moisturising, washing and bathing. This may include a combination of products or 1 product for all purposes.
The guideline adds that healthcare practitioners should offer an alternative emollient if a particular emollient causes irritation or is not acceptable to a child with atopic eczema.
Leave-on emollients should not be of a type that can cause harm to a child's skin. The full NICE guideline states that aqueous cream is associated with stinging when used as a leave-on emollient but it can be used as a wash product. Since the publication of the guideline there has been increasing concern about the use of sodium lauryl sulfate as an emulsifier (a substance used to mix oil with water to make creams) and an MHRA drug safety update in March 2013 advises that if a patient reports or shows signs of skin irritation with the use of aqueous cream, treatment should be discontinued and an alternative emollient that does not contain sodium lauryl sulfate should be tried.

Equality and diversity considerations

In recommending skin treatments, healthcare practitioners should be sensitive to the cultural practices of families or carers of children with atopic eczema. For example, if families or carers use olive oil as a skin treatment (which is likely to be harmful to a child's skin) or if they rinse children after bathing (rinsing off emollients), the reasons for using the recommended treatment and applying it correctly should be explained sensitively.

Referral for specialist dermatological advice

This quality statement is taken from the atopic eczema in under 12s quality standard. The quality standard defines clinical best practice for atopic eczema in under 12s and should be read in full.

Quality statement

Children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema are referred for specialist dermatological advice.

Rationale

Specialist dermatological advice may be beneficial for children with atopic eczema to improve the management of their condition. It can help to identify underlying reasons why the atopic eczema is not well controlled (including trigger factors such as contact allergens) or provide support if the condition has a negative impact on quality of life and psychosocial wellbeing. Parents' or carers' assessments of a child's physical or psychosocial wellbeing should be regarded as important determinants of the need for specialist dermatological advice.

Quality measures

Structure
Evidence of local arrangements for children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema to be referred for specialist dermatological advice.
Data source: Local data collection.

Process

The proportion of children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema who are referred for specialist dermatological advice.
Numerator: the number of children in the denominator who are referred for specialist dermatological advice.
Denominator: the number of children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that there are local arrangements for children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema to be referred for specialist dermatological advice.
Healthcare practitioners ensure that children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema are referred for specialist dermatological advice.
Commissioners ensure that they commission services with local arrangements to refer children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema for specialist dermatological advice.

What the quality statement means for patients and carers

Children with atopic eczema whose eczema does not improve after treatment, becomes infected repeatedly or causes them social or psychological problems are referred to a specialist.

Source guidance

Atopic eczema in children (NICE clinical guideline 57), recommendations 1.7.1.3 (key priority for implementation) 1.7.1.2 and 1.4.1.5 .

Definitions

Specialist dermatological advice
The referral should be to a specialist dermatological unit dealing with paediatric patients, for example a clinician with experience or qualifications in paediatric dermatology. This could include a paediatrician, specialist nurse or a GP with a specialist interest as long as they are within a dermatological unit and trained in paediatric dermatology.
NICE clinical guideline 57 recommends referral for specialist dermatological advice if the atopic eczema is not well controlled (including as assessed by the child, parent or carer), has not responded to treatment, is associated with recurring infections or if contact allergic dermatitis is suspected. Specialist dermatological advice should also be sought if the physical condition is giving rise to significant social or psychological problems for the child (or their parents or carers), including sleep disturbance or poor school attendance.
Onward referral for psychological advice can be made if necessary. NICE clinical guideline 57 recommends that children with atopic eczema that has responded to optimum management but for whom the impact of the atopic eczema on quality of life and psychosocial wellbeing has not improved should be referred for psychological advice.

Equality and diversity considerations

Healthcare practitioners should be aware of the potential difficulties of assessing eczema severity in children with darker skin tones.
Parent or carer assessment should be considered a good indicator of need for referral for all children. This must apply equally to all children regardless of socioeconomic status, and should not depend on the parents' or carers' ability to articulate a need for specialist care.

Specialist allergy investigation

This quality statement is taken from the atopic eczema in under 12s quality standard. The quality standard defines clinical best practice for atopic eczema in under 12s and should be read in full.

Quality statement

Infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment are referred for specialist investigation to identify possible food and other allergies.

Rationale

Infants and young children with moderate or severe atopic eczema have an increased likelihood of food and other allergies. Food allergies can cause a range of symptoms, including anaphylaxis, and can trigger or exacerbate atopic eczema. The most common food allergies for infants and young children with atopic eczema are to cows' milk, hens' eggs and nuts.
Specialist investigation can provide accurate identification of common food and other allergies; advice on dietary avoidance of allergens and choice of infant formula; and improved condition management strategies.

Quality measures

Structure
Evidence of local arrangements for infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment to be referred for specialist investigation to identify possible food and other allergies.
Data source: Local data collection.

Process

The proportion of infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment who are referred for specialist investigation to identify possible food and other allergies.
Numerator: the number of infants and young children in the denominator who are referred for specialist investigation to identify possible food and other allergies.
Denominator: the number of infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that there are local arrangements for infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment to be referred for specialist investigation to identify possible food and other allergies.
Healthcare practitioners ensure that infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment are referred for specialist investigation to identify possible food and other allergies.
Commissioners ensure that they commission services with local arrangements to offer infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment referral for specialist investigation to identify possible food and other allergies.

What the quality statement means for patients and carers

Infants and young children with moderate or severe atopic eczema that has not improved after treatment are referred to a specialist to find out whether they have any allergies that may be causing their eczema.

Source guidance

Atopic eczema in children (NICE clinical guideline 57), recommendations 1.4.1.2 (key priority for implementation), 1.7.1.3 (key priority for implementation) 1.7.1.5, 1.4.1.5, 1.4.1.7 and 1.4.1.8.

Definitions

Infants and young children
NICE clinical guideline 57 refers to a possible diagnosis of food allergy in infants and young children. The consensus of the quality standard Topic Expert Group is that this refers to children aged under 5 years.
Moderate or severe atopic eczema
NICE clinical guideline 57 defines moderate and severe atopic eczema as follows:
  • Moderate: areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening)
  • Severe: widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation).
Optimal treatment
Optimal treatment for atopic eczema for infants and young children refers to the stepped-care plan.
Specialist investigation
Referral for investigation into suspected food allergies may be to either a paediatric allergist or paediatric dermatologist, depending on the local availability of services. Other associated allergies (such as those to pollens or house dust mite) can also be investigated at the same time. Access to specialist allergy nurses and dieticians would normally be through the allergy team rather than a direct referral by a GP.

Treatment of eczema herpeticum

This quality statement is taken from the atopic eczema in under 12s quality standard. The quality standard defines clinical best practice for atopic eczema in under 12s and should be read in full.

Quality statement

Children with atopic eczema who have suspected eczema herpeticum receive immediate treatment with systemic aciclovir and are referred for same-day specialist dermatological advice.

Rationale

Eczema herpeticum (widespread herpes simplex virus) is a serious under-recognised condition and, if not diagnosed promptly, the child's condition may deteriorate rapidly. Eczema herpeticum can be fatal or can lead to blindness if not treated, and should therefore be an indication for urgent referral.

Quality measures

Structure
Evidence of local arrangements to ensure that children with atopic eczema who have suspected eczema herpeticum receive immediate treatment with systemic aciclovir and are referred for same-day specialist dermatological advice.
Data source: Local data collection.

Process

The proportion of children with atopic eczema who have suspected eczema herpeticum who receive immediate treatment with systemic aciclovir and are referred for same-day specialist dermatological advice.
Numerator: the number of children in the denominator who receive immediate treatment with systemic aciclovir and are referred for same-day specialist dermatological advice.
Denominator: the number of children with atopic eczema who have suspected eczema herpeticum.
Data source: Local data collection.

Outcome

Deaths of children with atopic eczema from eczema herpeticum.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that local arrangements are in place for children with atopic eczema who have suspected eczema herpeticum to receive immediate treatment with systemic aciclovir and to be referred for same-day specialist dermatological advice.
Healthcare practitioners ensure that children with atopic eczema who have suspected eczema herpeticum receive immediate treatment with systemic aciclovir and are referred for same-day specialist dermatological advice.
Commissioners ensure that they commission services with local arrangements to give children with atopic eczema who have suspected eczema herpeticum immediate treatment with systemic aciclovir and to refer them for same-day specialist dermatological advice.

What the quality statement means for patients and carers

Children with atopic eczema who have suspected eczema herpeticum (a rare but serious infection caused by the same virus that causes cold sores) receive immediate treatment with an antiviral drug (called systemic aciclovir), which can be given as medicine or an injection, and are referred immediately for same-day specialist advice.

Source guidance

Atopic eczema in children (NICE clinical guideline 57), recommendations 1.5.7.10, 1.5.7.11 1.5.7.12 (key priority for implementation) and 1.7.1.1.

Definitions

Suspected eczema herpeticum
Eczema herpeticum is a widespread herpes simplex virus. Signs of eczema herpeticum are:
  • areas of rapidly worsening, painful eczema
  • clustered blisters consistent with early-stage cold sores
  • punched-out erosions (circular, depressed, ulcerated lesions) usually 1–3 mm that are uniform in appearance (these may coalesce to form larger areas of erosion with crusting)
  • possible fever, lethargy or distress.
Specialist dermatological advice
The referral should be to a specialist dermatological unit dealing with paediatric patients, for example, a clinician with experience and qualifications in paediatric dermatology. This could include a specialist nurse or a GP with a specialist interest if they are working within a dermatological unit and trained in paediatric dermatology. If eczema herpeticum involves the skin around the eyes, the child should be referred for same-day ophthalmological and dermatological advice.
Systemic aciclovir
Oral or intravenous aciclovir can be given depending on the clinical situation. Aciclovir is likely to be given orally in primary care and intravenously in secondary care. The full NICE guideline recommends that if a child with atopic eczema has a lesion on the skin suspected to be herpes simplex virus, treatment with oral aciclovir should be started even if the infection is localised.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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
Skin/physical severity
Impact on quality of life and psychosocial wellbeing
Clear
Normal skin, no evidence of active atopic eczema
None
No impact on quality of life
Mild
Areas of dry skin, infrequent itching (with or without small areas of redness)
Mild
Limited impact on everyday activities, sleep and psychosocial wellbeing
Moderate
Areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening
Moderate
Moderate impact on everyday activities and psychosocial wellbeing, frequently disturbed sleep
Severe
Widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation
Severe
Severe limitation of everyday activities and psychosocial functioning, nightly loss of sleep
The following recommendations are from NICE technology appraisal guidance on tacrolimus and pimecrolimus for atopic eczema.
Topical tacrolimus and pimecrolimus are not recommended for the treatment of mild atopic eczema or as first-line treatments for atopic eczema of any severity.
Topical tacrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate to severe atopic eczema in adults and children aged 2 years and older that has not been controlled by topical corticosteroids, where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy.
Pimecrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate atopic eczema on the face and neck in children aged 2 to 16 years that has not been controlled by topical corticosteroids, where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy.
For the purposes of this guidance, atopic eczema that has not been controlled by topical corticosteroids refers to disease that has not shown a satisfactory clinical response to adequate use of the maximum strength and potency that is appropriate for the patient's age and the area being treated.
It is recommended that treatment with tacrolimus or pimecrolimus be initiated only by physicians (including general practitioners) with a special interest and experience in dermatology, and only after careful discussion with the patient about the potential risks and benefits of all appropriate second-line treatment options.
NICE has written information for the public explaining its guidance on tacrolimus and pimecrolimus.

Glossary

Dermatology Life Quality Index
Physician Global Assessment

Paths in this pathway

Pathway created: August 2012 Last updated: May 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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