Atopic Eczema

1. Nice guide lines 2007 Atopic Eczema

2. Diagnosis • Itching plus 3 or more of • Visible flexural dermatitis involving skin creases, cheeks or extensor surfaces • History of flexural dermatitis involving skin creases, cheeks or extensor surfaces • History of dry skin in last year • History of atopic disease (asthma rhinitis eczema) in first degree relative aged < 4yrs • Onset under 2 yrs (use only in those > 4 yrs at diagnosis

3. Assessment of severity • Clear – normal skin no evidence of active atopic eczema • Mild – areas of dry skin, frequent itching +- small areas of redness • Moderate - areas of dry skin, frequent itching, redness, +- excoriation and localised thickening. • Severe – widespread areas of dry skin, incessant itching, redness (+- excoriation, extensive skin thickening, bleeding, oozing, cracking.

4. Impact on quality of life • None – no impact on quality of life • Mild – little impact on everyday activities, sleep and psychosocial well being • Moderate - Moderate impact on everyday activities, psychosocial well being, frequently disturbed sleep • Severe – severe limitation of everyday activities and psychosocial well being, loss of sleep every night

5. Holistic approach • Take account of • Physical severity of eczema • Impact on quality of life • Psychosocial functioning • Any loss of sleep • No direct correlation between physical severity of eczema and impact on quality of life

6. Management • Identify trigger factors • Irritants – soaps and detergents • Contact allergens • Food allergens • Inhalant allergens • Skin infections • Refer for specialist advice when necessary

7. Stepped treatment • Tailor treatment to severity • Start with emollients – should be used even when skin clear • Mild disease – emollients + mild steroid creams 1% hydrocortisone • Moderate disease – emollients + moderate steroid creams. Topical calcineurin inhibitors, bandages. • Severe disease – potent steroid creams (short periods only) topical calcineurin inhibitors, bandages, phototherapy, systemic therapy

8. Management • Use topical antibiotics + steroid for localised infection for no longer than 2 weeks • Non-sedating antihistamines if eczema is severe or severe itching or urticaria • Sedating antihistamines children aged > 6/12 during acute flares if sleep disturbance for child or carers. • Recognise indications for referral

9. Indications for referral • Immediate (same day) • if eczema herpeticum suspected • Urgent (within 2 weeks) • If severe and not responded to optimal treatment for 1 week • Treatment of bacterial infected eczema has failed

10. Indications for referral • Routine referral • Diagnosis uncertain • Eczema on face not responded • Eczema is associated with sever recurrent infections • Contact allergic eczema suspected • Causing serious social or psychological problems for child or carers • Eczema not controlled to the satisfaction of carers or child

11. Education and information • Explain cause and course of disease • Demonstrate quantities and frequency of treatments • Inform symptoms and signs of bacterial infections • How to recognise eczema herpeticum • Ask about use of complementary therapies explain have not be assessed for safety. Should continue to use emollients as well as complimentary therapies

12. Overcoming • Discuss parental anxieties about treatments explain benefits of steroids outweigh possible harms • Written care plans including management of flare ups and infections • Explain when topical steroids and other treatments are indicated