Guidelines for the outpatient management of childhood eczema

Read these guidelines in association with:

• Guidelines for the diagnosis and assessment of eczema
• Guidelines for the management of adult eczema

The majority of children with eczema can be managed in an outpatient setting.

Treatment should be prescribed as a package including:

• Advice regarding avoidance of triggers/irritants
• Advice regarding bathing and soap substitutes
• Moisturisers (emollients)
• Topical corticosteroids/calcineurin inhibitors
• Antibiotics and antihistamines if needed
• Advice regarding recognition of infection
• A clear plan for review by a health professional

Prescribers need to spend time to ensure that children and their caregivers understand all aspects of therapy and how to use them.

Prescriptions for topical treatments should be supported with verbal instructions, written information (eg eczema action plan, handouts) and demonstration (eg videos). Education from an eczema nurse has been shown to improve adherence and the effectiveness of treatment.[1]

Resources for families

1. kidshealth.org.nz: includes videos and handouts

Resources for prescribers include:

• NICE guidelines [2]
• SafeRx Eczema in Children [3]
• Healthpoint pathways [4]

Baths

• Baths are advised once or twice daily.
• It is recommended that water is warm and that baths last no more than 10 minutes.
• Emollient or emollient wash products should be used instead of soap and shampoo.
• Bath oils help moisturise the skin, but can make the bath slippery. A trial published in 2018 indicated that bath additives may have no value.
• Regular antiseptic baths twice weekly with dilute sodium hypochlorite (bleach baths) or triclosan bath oils may reduce Staphylococcal carriage and improve eczema.[5]

Emollients/moisturisers

• Children should be provided with emollients to use every day for moisturising, washing and bathing. These should not be perfumed and, where possible, fully funded on prescription.
• Children should be provided with 250–500 g of emollient per week.
• Emollients should be applied several times a day to the entire body and continued even when the eczema has cleared.
• Emollients should be smoothed (not rubbed) on in the direction of hair growth. They can be allowed to soak in.
• When possible emollient should be provided in a pump container or tube. Emollients in open containers can become contaminated. Emollient should be decanted from tubs using a clean spoon or spatula before each use. Tubs should be discarded after an episode of skin infection.
• If an emollient irritates or is disliked by the child then an alternative should be offered.
• Increased use of emollients has been associated with improved eczema and reduced need for topical corticosteroids

Topical corticosteroids

The benefits and harms of topical corticosteroids should be discussed with the family/caregivers, emphasizing that benefits outweigh possible harms when they are used correctly.

The potency of topical corticosteroids should be tailored to the child’s eczema:

Mild potency

• For mild eczema
• For infants <12 months
• For the face and neck

Moderate potency

• For moderate eczema
• For short term 5–7 day use in the axillae and groin and for severe facial flares

Potent

• For severe eczema
• Not recommended for use on the face and neck

Do not use super potent topical corticosteroids in children (or potent in children under the age of 12 months) without specialist dermatological advice.[2]

• Topical corticosteroids should only be applied to areas of active eczema, and stopped when the eczema has gone. Emollients should be continued.
• Topical corticosteroids should be applied in a thin layer to the affected area once or twice daily. They can be applied before or after emollients.
• Diluting topical corticosteroids in emollient or other products has not been shown to reduce potency.
• Long term continuous use of topical steroids can rarely result in side effects eg skin thinning, and adrenal suppression with widespread application. It is recommended that children using topical steroids are reviewed regularly and treatment stepped down in frequency as possible. Children requiring continuous use of topical steroid should be reviewed by a dermatologist.
• Long term maintenance use of topical steroids 2 days per week (‘weekend treatment’) seems safe and effective. [6]

Topical calcineurin inhibitors

• Topical calcineurin inhibitors (TCIs) are a second-line therapy for eczema that has failed to respond to appropriate topical corticosteroids. TCIs may be considered when there is a risk of side effects from topical corticosteroids.
• The risks and benefits of TCIs should be discussed with the patient and caregivers, and other options for treatment discussed. It is recommended that they are not used without specialist dermatological advice [2]
• Topical pimecrolimus is licenced for use for eczema on the face and neck in children over 2 years of age.
• Topical tacrolimus is not registered in New Zealand.

Antihistamines

• Antihistamines are not recommended for routine use.
• A short (<1 month) trial of a non-sedating antihistamine may be considered for moderate-severe eczema or where there is associated urticaria. The benefit of ongoing use should be reviewed every 3 months.
• Sedating antihistamines may be used to aid sleep during acute flares in children over 6 months of age.[2]

Antibiotics

• Topical antibiotics may be used for localised (< 5 cm) areas of skin infection for up to 7 days.
• Systemic antibiotics should be prescribed for 7–14 days to treat generalised infection.
• The choice of antibiotics will depend on local antibiotic resistance patterns, but should be active against Staphylococcus aureus and Streptococci. [4]

Reassess

If there is no improvement after 7–14 days of treatment then the following should be considered:

• Incomplete adherence to prescribed treatments
• Ongoing exposure to irritants eg sodium lauryl sulphate, soap
• Inadequate amount or potency of topical corticosteroid applied
• Secondary infection of the skin
• Contact allergy eg to prescribed products or aeroallergens
• Incorrect diagnosis

When to refer