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.

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.

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