Intended for healthcare professionals

Clinical Review

Management of difficult and severe eczema in childhood

BMJ 2012; 345 doi: (Published 23 July 2012) Cite this as: BMJ 2012;345:e4770
  1. M A McAleer, specialist registrar1,
  2. C Flohr, clinical senior lecturer2,
  3. A D Irvine, professor134
  1. 1Department of Paediatric Dermatology, Our Lady’s Children’s Hospital, Crumlin, Dublin 12, Republic of Ireland
  2. 2Department of Paediatric Dermatology, St John’s Institute of Dermatology, Guy’s and St Thomas’ Hospitals NHS Foundation Trust and King’s College, London, UK
  3. 3Clinical Medicine, Trinity College, Dublin, Republic of Ireland
  4. 4National Children’s Research Centre, Dublin, Republic of Ireland
  1. Correspondence to: A D Irvine irvinea{at}
  • Accepted 2 July 2012

Summary points

  • Eczema is associated with serious morbidity for the patient and family

  • Patient education is essential for the treatment of this complex chronic disorder

  • Topical anti-inflammatory drugs together with regular use of emollients is effective in most children with eczema

  • Patients with eczema are susceptible to molluscum contagiosum and infection with Staphylococcus aureus and herpes simplex virus; infections can cause disease flares and treatment resistance

  • Patients with severe eczema may need systemic immunomodulatory drugs, which require close monitoring by a doctor experienced in their use

Childhood eczema is the most common inflammatory skin disease and affects around 20% of children in the United Kingdom.w1 The condition is also referred to as atopic dermatitis and atopic eczema. The correct nomenclature is debated by experts. The World Allergy Organisation recommends the term eczema, and this is widely used in the UK literature. Atopic dermatitis is perhaps the more accepted term historically and internationally. In this review we will use the term eczema.

Eczema is associated with several comorbidities, including food and respiratory allergies. It has a serious effect on children’s and families’ quality of life—for example, through sleep disturbance and a negative impact on schooling.1 2 3 The resulting impairment in health related quality of life is comparable to that of other chronic diseases of childhood, including diabetes and asthma.1

Although mild eczema can often be managed in primary care, around 2% of patients have severe disease that does not respond to topical anti-inflammatory drugs or ultraviolet light treatment alone. These recalcitrant cases require intensive expert management and an individualised approach, especially when systemic immunomodulatory drugs are used. Although these drugs are often life transforming, their side effects require close monitoring. Currently, there is a distinct lack of evidence to help guide the clinician caring for children with …

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