Practice Guidelines

Management of atopic eczema in children aged up to 12 years: summary of NICE guidance

BMJ 2007; 335 doi: http://dx.doi.org/10.1136/bmj.39405.503773.AD (Published 13 December 2007) Cite this as: BMJ 2007;335:1263
  1. Sue Lewis-Jones, consultant dermatologist1,
  2. Moira A Mugglestone, deputy director2
  3. on behalf of the Guideline Development Group
  1. 1Ninewells Hospital and Medical School, Dundee DD1 9SY
  2. 2National Collaborating Centre for Women’s and Children’s Health, London W1T 2QA
  1. Correspondence to: M A Mugglestone mmugglestone{at}ncc-wch.org.uk

    Why read this summary?

    Atopic eczema affects one in five children in the United Kingdom1 and accounts for 1 in 30 consultations in community care.2 Recent data suggest that impaired skin barrier function is a major causative factor.3 4 There may be considerable physical and emotional morbidity for the child and the parents or carers, particularly if the disease is poorly controlled.5 Yet most healthcare professionals receive little or no relevant training in dermatology,6 and lack of knowledge, confusion, and anxiety about many of the available treatments are widespread among parents.5 7 This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) on how to manage atopic eczema in children from birth up to the age of 12 years.8

    Recommendations

    NICE recommendations are based on systematic reviews of the best available evidence. When minimal evidence is available, a range of consensus techniques is used to develop recommendations. In this summary, recommendations derived primarily from consensus techniques are indicated with an asterisk (*).

    Diagnosis and assessment

    • • Diagnose atopic eczema in children according to the criteria in box 1.

    • • Adopt a holistic approach to assessing a child’s atopic eczema*, taking account of the physical severity of the eczema (box 2) and its impact on quality of life (which may range from no impact to severe limitation of everyday activities and psychosocial functioning, with loss of sleep each night (box 3). This assessment should guide treatment decisions; no direct relation necessarily exists between physical severity of atopic eczema and impact on quality of life.

    Box 1 Criteria for diagnosing atopic eczema in children

    Itching plus three or more of:

    • Visible flexural dermatitis involving skin creases (or involvement of cheeks and/or extensor surfaces in children aged up to 18 months)

    • History of flexural dermatitis (or involvement of cheeks and/or extensor surfaces in children aged up to 18 months)

    • History of dry skin in past 12 months

    • History of asthma or allergic rhinitis (or history of atopic disease in a first degree relative in children aged under 4 years)

    • Onset under the age of 2 years (but this criterion should be used only for children aged 4 years or more at time of diagnosis)

    Box 2 Categorisation of physical severity of atopic eczema

    • Clear—Normal skin, with 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)

    Box 3 Categorisation of impact of atopic eczema on quality of life

    • 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; loss of sleep every night

    Management

    • Identify and manage trigger factors, including irritants (soaps and detergents) and, in some children, skin infections, contact allergens, food allergens, and/or inhalant allergens; refer for specialist advice when necessary.

    • Emollients are the basis of management and should be used even when the skin is clear.

    • Adopt a stepped approach to management (box 4), using emollients with or without treatments such as topical corticosteroids, topical calcineurin inhibitors, and bandaging techniques; step treatment up or down according to clinical response, recognising that atopic eczema typically comprises exacerbations (flares) and remissions.

    • Use topical antibiotics, including those combined with topical corticosteroids, for localised infection only and for no longer than two weeks.

    • Offer non-sedating antihistamines if eczema is severe or if severe itching or urticaria occurs; offer sedating antihistamines to children aged over 6 months during acute flares if sleep disturbance is severe for the child or their parents or carers.

    • Recognise the indications for referral for specialist dermatological advice (box 5).*

    Box 4 Stepped approach to management of atopic eczema

    • Tailor treatment to severity

    • Step treatment up or down according to clinical response. Always use emollients, even when the skin is clear, and add other treatments when required, with specialist advice where recommended

    • Mild atopic eczema—Use mild potency topical corticosteroids

    • Moderate atopic eczema—Use moderate potency topical corticosteroids, topical calcineurin inhibitors, bandages

    • Severe atopic eczema—Use potent topical corticosteroids (short periods only except under specialist supervision), topical calcineurin inhibitors, bandages, phototherapy, systemic therapy

    Box 5 Indications for referral for specialist dermatological advice*

    Immediate (same-day) referral
    • If eczema herpeticum is suspected

    Urgent referral (seen within two weeks)
    • If the atopic eczema is severe and has not responded to optimal topical therapy after 1 week

    • If treatment of bacterially infected atopic eczema has failed

    Routine (non-urgent) referral

    If any of the following apply:

    • The diagnosis is or has become uncertain

    • Atopic eczema on the face has not responded to appropriate treatment

    • The atopic eczema is associated with severe and recurrent infections

    • Contact allergic dermatitis is suspected

    • The atopic eczema is giving rise to serious social or psychological problems for the child, parent, or carer

    • The child, parent, or carer might benefit from specialist advice on treatment application

    • Management has not controlled the atopic eczema satisfactorily according to a subjective assessment by the child, parent, or carer

    Education and information

    • Educate children and their parents or carers about atopic eczema, including practical demonstrations of the quantities and frequency of treatments to be used.

    • Inform them about symptoms and signs of bacterial infection of atopic eczema: weeping, pustules, crusts, eczema failing to respond to treatment, rapidly worsening eczema, fever, and malaise.

    • Inform them about how to recognise eczema herpeticum (widespread herpes simplex virus): areas of rapidly worsening, painful eczema; clustered blisters consistent with early stage cold sores; punched-out erosions that are uniform in appearance and may coalesce; possible fever; lethargy; or distress.

    • Ask about their use of complementary therapies; explain that the effectiveness and safety of such therapies (homoeopathy, herbal medicine, massage, and food supplements) have not been adequately assessed in clinical studies; and inform them that they should continue to use emollients if they choose to use complementary therapies.

    Overcoming barriers

    If used correctly, the structured approach recommended in this guidance should allow improved quality of care and more cost effective clinical management of atopic eczema. The approach requires an initial investment in time to assess the child’s atopic eczema adequately and discuss parental anxieties about treatments, emphasising that the benefits of topical corticosteroids outweigh possible harms. Written care plans should cover treatment of flares and episodes of infected eczema to educate parents on when topical corticosteroids (and other treatments) are appropriate. This investment should, however, lead to longer term benefits, empowering children with atopic eczema and their parents or carers to take control of management, and potentially reducing the need for frequent monitoring and thus the workload of healthcare professionals.

    To support implementation, NICE and the guideline development group have developed a version of the guidance (available from December 2007 at www.nice.org.uk/CG057PublicInfoEnglish) that can be given to children with atopic eczema and their parents or carers).

    Further information on the guidance

    Background

    A study conducted in the United Kingdom in 2003 reported a lifetime prevalence of atopic eczema in 12 year olds of 23%.1 Similar lifetime prevalence figures were reported in two other studies conducted in the United Kingdom (20% in children aged 3-11 yearsw1 and 25% in children aged 8 yearsw2), although a third study reported a lifetime prevalence of 41% in children aged 10 years.w3 Despite the frequency of consultations for eczema in community care (dermatological conditions account for 15% of such consultations, of which 22% involve eczema2), general practitioners lack dermatological knowledge and training.4 w4

    The aim of the new guidance is to provide a framework for healthcare professionals to empower children with atopic eczema and their parents or carers to manage the condition effectively, thus alleviating the negative impact on their quality of life. The guidance encompasses education and information about topical treatments, including topical corticosteroids, which are currently a source of confusion and anxiety for many parents and limit adherence to treatment.3 5 w5

    What’s new?

    Recent studies have linked ichthyosis vulgaris, the commonest inherited type of dry skin, to a high risk of developing atopic eczema, which may be severe and persistent.3 4 This supports the belief that inheritance of genetic traits causing impaired skin barrier function is a major factor in the development of atopic eczema. Strategies to improve skin barrier function, such as reduction of irritants and the use of emollients, as recommended in the guidance, are vital for successful treatment.

    Methods

    The guidance was developed by the National Collaborating Centre for Women’s and Children’s Health in accordance with NICE guideline development methods (see www.nice.org.uk/page.aspx?o=114219). The collaborating centre established a guideline development group consisting of healthcare professionals and patient and carer representatives, with experts in guideline methodology from the collaborating centre. The guideline development group identified and appraised clinical effectiveness evidence and evaluated cost effectiveness of interventions where possible. Stakeholder organisations were invited to comment on a draft of the guideline that was subsequently revised to take account of comments received.

    NICE has produced four different versions of the guideline: a full version containing all the evidence and the recommendations; a quick reference guide; a version known as the “NICE guideline” that lists the recommendations; and a version for patients and the public. All these versions are available from the NICE website (www.nice.org.uk/CG057). Future updates of the guidance will be produced as part of the NICE guideline development programme.w6

    Key areas for future research
    • Optimal feeding regimens for children aged under 1 year with established atopic eczema

    • Treatment strategies for managing and preventing flares of atopic eczema in children

    • The effect of controlling atopic eczema in children aged under 1 year on subsequent development and severity of other atopic diseases

    • Long term effects of topical corticosteroids for atopic eczema in children

    • Clinical and cost effectiveness of different models of education in the early management of atopic eczema in children

    Extra references

    • w1 Kay J, Gawkrodger DJ, Mortimer MJ, Jaron AG. The prevalence of childhood atopic eczema in a general population. J Am Acad Dermatol 1994;30:35-9.

    • w2 Harris JM. Early allergen exposure and atopic eczema. Br J Dermatol 2007;156:698-704.

    • w3 Kurukulaaratchy R, Fenn M, Matthews S, Arshad H. The prevalence, characteristics of and early life risk factors for eczema in 10-year-old children. Pediatr Allergy Immunol 2003;14:178-83.

    • w4 Schofield JK, Adlard TP, Heatley P, Gunn S. A study of the dermatological knowledge of general practitioner (GP) registrars: implications for GP training programmes. Br J Dermatol 2003;149(suppl 64):19-56.

    • w5 Charman CR, Morris AD, Williams HC. Topical corticosteroid phobia in patients with atopic eczema. Br J Dermatol 2000;142:931-6.

    • w6 National Institute for Health and Clinical Excellence. Updating guidelines and correcting errors. In: The guidelines manual. (Ch 15.) www.nice.org.uk/page.aspx?o=423088.

    Members of the Guideline Development Group

    • Denise Carr, general practitioner with special interest in dermatology, Eden Park Surgery, Beckenham

    • Christine Clark, medical writer and independent pharmaceutical consultant, Rossendale

    • Michael J Cork, head of academic dermatology, Academic Unit of Biomedical Genetics-Dermatology, The University of Sheffield School of Medicine and Biomedical Sciences, and honorary consultant dermatologist, Sheffield Children’s Hospital and Sheffield Teaching Hospitals NHS Foundation Trust

    • Helen Cox, consultant in paediatric allergy and immunology, Imperial College Healthcare NHS Trust, London

    • Elizabeth Gilmour, consultant dermatologist, Tameside General Hospital, Ashton-under-Lyne, and Booth Hall Children’s Hospital, Manchester

    • Wendy Lancaster, health visitor, North Yorkshire and York Primary Care Trust, Haxby and Wigginton Health Centre, York

    • Sandra Lawton, nurse consultant dermatology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust

    • Sue Lewis-Jones, consultant dermatologist, Ninewells Hospital, and honorary senior lecturer, Ninewells Hospital and Medical School, Dundee, and University of Dundee

    • Sarah Purdy, consultant senior lecturer in primary health care, University of Bristol, and general practitioner, Bristol

    • Amanda Roberts, patient/carer representative, Nottingham

    • Jean Robinson, clinical nurse specialist (paediatric dermatology), Barts and The London NHS Trust, Royal London Hospital

    • Sue Ward, information and education manager, National Eczema Society, London

    National Collaborating Centre for Women’s and Children’s Health staff
    • Paula Broughton-Palmer, senior work programme coordinator, National Collaborating Centre for Women’s and Children’s Health, London

    • Hannah-Rose Douglas, senior health economist, National Collaborating Centre for Women’s and Children’s Health

    • Alyson Huntley, freelance systematic reviewer, Exeter

    • Moira A Mugglestone, deputy director, National Collaborating Centre for Women’s and Children’s Health

    • Anne Marie O’Connell, information specialist, National Collaborating Centre for Women’s and Children’s Health

    • Julia Saperia, research fellow, National Collaborating Centre for Women’s and Children’s Health

    Footnotes

    • This is one of a series of BMJ summaries of new guidelines, which are based on the best available evidence; they will highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

    • Contributors: SL-J and MAM wrote the initial draft of the article using material produced collectively by the entire guideline development group and contributed to its revision and the final draft, having received feedback from every member of the group. MAM established the group and was project director. SL-J chaired the group.

    • Funding: The National Collaborating Centre for Women’s and Children’s Health was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.

    • Competing interests: SL-J has received funding from pharmaceutical companies (for advisory services, conference expenses, lecture fees, course sponsorship, and research), the British National Formulary (for reviewing treatments), the Primary Care Dermatology Society (lecture fees), the Anonymous Trust, the British Skin Foundation, and EastRen Research (research funding); she is a trustee of the British Skin Foundation and co-holder of copyright for quality of life questionnaires (she abstained from the guideline development group’s decision making on quality of life questionnaires). CC holds shares in GlaxoSmithKline and Shire and has received funding from pharmaceutical companies and the Royal Pharmaceutical Society of Great Britain (for consultancy and medical writing services). MC holds shares in York Pharma and Strakan Pharmaceuticals and has received funding from pharmaceutical companies (for consultancy, conference expenses, and research). AH has been commissioned to write for MIMS Dermatology. SL has received funding from pharmaceutical companies (for conference expenses, lecture fees, and course sponsorship) and is a member of the National Eczema Society and of the advisory group for the All Party Parliamentary Group on Skin. AR holds shares in the Boots group, is a member of the East Midlands Regional Funding Committee for the Research for Patient Benefit Programme of the National Institute for Health Research and is involved in running the Nottingham Support Group for Carers of Children with Eczema, which has been invited to participate in research for pharmaceutical companies. JR holds shares in Reckitt Benckiser and has received funding from pharmaceutical companies (for development of educational tools). SW is an employee of the National Eczema Society, which receives funding from pharmaceutical companies, and has received funding to write about trigger factors in eczema.

    • Provenance and peer review: Commissioned; not externally peer reviewed.

    References