BMJ  2005;331:497 (3 September), doi:10.1136/bmj.331.7515.497

Primary care

10 minute consultation

Childhood eczema

¹ Tayside Centre for General Practice, University of Dundee, Dundee DD2 4AD, ² Ninewells Hopsital, Dundee DD1 9SY

Introduction

A 9 month old infant presents with his mother with a three month history of dry, red, itchy rash, initially on the face and extensor surfaces of limbs but now affecting flexor surfaces too.

What issues you should cover

• Is this really eczema? (see box).
  
• What impact are symptoms having?
  
• Is the baby distressed by itching? Is this keeping him awake, and what is the effect on the family?
  
• What have they tried?
  

Eczema is a visible, distressing condition, and parents may already have received an abundance of conflicting advice. They may have tried over the counter preparations, dietary exclusions, or alternative therapies.

What you should do

Confirm the diagnosis by thorough examination and exclude secondary infection.

Drug treatment—Prescribe an emollient in sufficient quantities. (Infants require 250 g per week, to be applied twice daily.) Advise that several different products may be tried before the most suitable is found. In general, greasy ointments are preferable for dry skin or at night, and creams are preferable for inflamed areas and during the day. Prescribe a bath additive or soap substitute, or both. Because the skin is very inflamed, prescribe a mild topical steroid (such as hydrocortisone 1% ointment). Emphasise that this is for short term, intermittent use and should be avoided near the eyes. Once daily administration, rather than twice daily, is recommended as a first step. There is no evidence for prescribing combinations of topical steroids and antimicrobials over steroids alone. Exudate or crusting suggests secondary bacterial infection, and topical antibiotics should be started, with consideration of local resistance. Systemic antibiotics may be needed in more severe cases or if topical treatment is ineffective. Consider swabs if adequate antimicrobial therapy seems ineffective. Herpetic vesicles suggest the rare but dangerous condition of eczema herpeticum, which should be referred urgently by phone. If sleep disruption is a problem, consider short term treatment with an antihistamine, such as hydroxyzine. Evening primrose oil is ineffective in eczema.

Diagnostic criteria for atopic eczema Must have itchy skin condition (or report of scratching or rubbing in a child), plus three or more of the following: History of itchiness of flexor surfaces or around the neck (or the cheeks in children under 4 years) Visible flexural eczema (or eczema affecting the cheeks or forehead and outer limbs in children under 4 years) History of asthma or hay fever (or history of atopic disease in a first degree relative in children under 4 years) General dry skin in the past year Onset in the first two years of life (not always diagnostic in children under 4 years)

Useful reading www.eczema.org—National Eczema Society, which also provides leaflets British National Formulary (www.bnf.org)—advice on emollients (section 13.2) and on the potency of different steroid preparations (section 13.4) McHenry P, Williams H, Bingham E. Fortnightly review: management of atopic eczema. BMJ 1995;310: 843-7.[Abstract/Free Full Text] Hoare C, Li Wan Po A, Williams H. Systematic review of treatments for atopic eczema. Health and Technology Assessment 2000;4: 1-191. Smethurst D, Macfarlane S. Atopic eczema. Clinical Evidence 2003;9: 1785-803.

Preventive treatment—Emphasise commonsense approaches such as avoiding soap, biological washing detergents, shampoo, or bubble baths; keeping nails short; and avoiding wool or nylon clothing (advise cotton instead). Some parents may wish to reduce environmental allergens such as house dust mite and pet dander, although there is insufficient evidence at present to recommend this. Food allergy is a relatively uncommon cause of atopic eczema, occurring in perhaps 10% of infants. Egg and milk are the commonest allergens and should be considered if severe eczema persists despite adequate treatment, in which case dietetic advice should be sought. Eczema alone is not a reason to avoid vaccination.

Follow-up—Acknowledge parental concerns. To prevent flare-ups, encourage continuation of emollients even when eczema has cleared. Reassure the parent that hydrocortisone 1% is a weak steroid and advise that intermittent use will probably be necessary. Advise that treatment cannot cure but should improve symptoms. About 75% of children outgrow their eczema by their early teens. Encourage re-attendance, to ensure adequate explanation and education; it is essential if regular topical steroids are required. Involvement of a member of the primary care team such as a health visitor or practice nurse with appropriate training in dermatology would be useful. Give written information. Referral to dermatology at first presentation is probably unnecessary unless there is diagnostic uncertainty or treatment failure or if the impact of the eczema is severe.

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This is part of a series of occasional articles on common problems in primary care

The series is edited by general practitioners Ann McPherson and Deborah Waller (ann.mcpherson{at}dphpc.ox.ac.uk)

The BMJ welcomes contributions from general practitioners to the series

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This article has been cited by other articles:

• Simon, C. (2008). Childhood atopic eczema. InnovAiT 1: 423-429 [Abstract] [Full text]  

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