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Guidelines for the outpatient / primary care managment of childhood eczema

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Guidelines for the outpatient/primary care management of childhood eczema

The majority of children with eczema can be managed in an outpatient setting.

Treatment should be prescribed as a package including:

Prescribers need to spend time to ensure that children and their caregivers understand all aspects of therapy and how to use them.

Prescriptions for topical treatments should be supported with verbal instructions, written information (eg eczema action plan, handouts) and demonstration (eg videos). Education from an eczema nurse has been shown to improve adherence and the effectiveness of treatment.[1]

Resources for families

(see Family Information and Handouts)

Resources for prescribers include:

In This Guideline

Baths
Emollients/moisturisers
Topical corticosteroids
Topical calcineurin inhibitors
Antihistamines
Antibiotics
Wet wraps
Reassess
Systemic therapy
When to refer

Baths

Baths are advised once or twice daily.

It is recommended that water is warm and that baths last no more than 10 -15 minutes.

Emollient or emollient wash products should be used instead of soap and shampoo.

Bath oils help moisturise the skin, but can make the bath slippery.

Regular antiseptic baths twice weekly with dilute sodium hypochlorite (bleach) or triclosan bath oils may reduce Staphylococcal carriage and improve eczema.[5, 6]

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Emollients/moisturisers

Children should be provided with emollients to use every day for moisturising, washing and bathing. These should not be perfumed and, where possible, fully funded on prescription.

Children should be provided with 250 - 500g of emollient per week.

Emollients should be applied several times a day to the entire body and continued even when the eczema has cleared.

Emollients should be smoothed (not rubbed) on in the direction of hair growth. They can be allowed to soak in.

When possible emollient should be provided in a pump container or tube. Emollients in open containers can become contaminated. Emollient should be decanted from tubs using a clean spoon or spatula before each use. Tubs should be discarded after an episode of skin infection.

If an emollient irritates or is disliked by the child then an alternative should be offered.

Increased use of emollients has been associated with improved eczema and reduced need for topical corticosteroids [8]

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Topical corticosteroids

The benefits and harms of topical corticosteroids should be discussed with the family/caregivers, emphasizing that benefits outweigh possible harms when they are used correctly.

The potency of topical corticosteroids should be tailored to the child's eczema:

Topical corticosteroids should only be applied to areas of active eczema, and stopped when the eczema has gone. Emollients should be continued.

Topical corticosteroids should be applied in a thin layer to the affected area once or twice daily. They can be applied before or after emollients.

Diluting topical corticosteroids in emollient or other products has not been shown to reduce potency.

Long term continuous use of topical steroids can rarely result in side effects eg skin thinning, adrenal suppression with widespread application. It is recommended that children using topical steroids are reviewed regularly and treatment stepped down in frequency as possible. Children requiring continuous use of topical steroid should be reviewed by a dermatologist.

Long term maintenance use of topical steroids 2 days per week ('weekend treatment') seems safe and effective. [7]

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Topical calcineurin inhibitors

Topical calcineurin inhibitors (TCIs) are a second-line therapy for eczema that has failed to respond to appropriate topical corticosteroids. TCIs may be considered when there is a risk of side effects from topical corticosteroids.

The risks and benefits of TCIs should be discussed with the patient and caregivers, and other options for treatment discussed. It is recommended that they are not used without specialist dermatological advice [2]

Topical pimecrolimus is licenced for use for eczema on the face and neck in children over 2 years of age.

Topical tacrolimus is not registered in New Zealand.

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Antihistamines

Antihistamines are not recommended for routine use as these often do not help with itch in eczema.

A short (<1 month) trial of a non-sedating antihistamine may be considered for moderate-severe eczema or where there is associated urticaria. The benefit of ongoing use should be reviewed every 3 months.

Sedating antihistamines may be used to aid sleep during acute flares in children over 6 months of age.[2]

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Antibiotics

Topical antibiotics may be used for localized (<5cm) areas of skin infection for up to 7 days.

Systemic antibiotics should be prescribed for 7 - 14 days to treat generalized infection.

The choice of antibiotics will depend on local antibiotic resistance patterns, but should be active against Staphylococcus aureus and Streptococci. [4]

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Wet wraps

Wet wraps involve a layer of damp bandaging covered by a layer of dry bandaging. They increase penetration of topical agents through the skin.

Use of whole body wet wraps with topical corticosteroids should be short term (less than 7 days) and with close medical supervision as systemic absorption of corticosteroids will occur. Monitoring of growth and early morning cortisol is essential if used long term (9).

Wet wraps with corticosteroids should only be commenced by a medical professional experienced in their use, and initiation in a hospital setting is generally preferred. In an outpatient setting, the benefit of wet wraps with topical corticosteroids over correct application topical corticosteroids alone is not clear (9). Wet wraps are not recommended in the presence of infection.

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Reassess

If there is no improvement after 7-14 days of treatment then the following should be considered:

Considerations in cases of treatment failure in eczema
Incomplete adherence to prescribed treatments
Ongoing exposure to irritants eg sodium lauryl sulphate, soap 
Inadequate amount or potency of topical corticosteroid applied 
Secondary infection of the skin 
Contact allergy eg to prescribed products or aeroallergens 
Incorrect diagnosis 

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Systemic therapy

It is recommended that treatment of severe recalcitrant eczema with phototherapy or systemic immunosuppressants (eg methotrexate, cyclosporine, azathioprine) be instituted by or in conjunction with a specialist dermatologist. Treatment with oral prednisone is not generally recommended for eczema due to significant rebound flaring on withdrawal.

When possible, it is advised that all immunisations are brought up to date, and that vaccination against varicella is performed prior to initiating immunosuppressive treatment for eczema.

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When to refer

Referral for specialist advice is recommended in the following circumstances:

When to refer
Referral for inpatient care • Eczema herpeticum is suspected
• Eczema is severe and not responding to treatment
• Bacterially infected eczema is not responding to
  appropriate treatment
• For education, support and respite in select cases 
Referral for eczema nurse advice • Where the patient and caregivers would benefit from advice
  and support regarding correct use of treatment
Referral for specialist dermatologist advice  • The diagnosis is uncertain
• Eczema on the face has not responded to treatment
• Contact dermatitis is suspected
• Eczema is causing significant psychological or social
  problems
• Eczema is associated with severe or recurrent infections
• The family or child would benefit from specialist advice on
  treatment
• Where phototherapy or systemic treatment is required 
Referral for psychological advice  • Children with ongoing psychological or social impact
  despite appropriate medical advice
Referral for specialist paediatric advice • Children with suspected immediate food hypersensitivity
• Children with poor growth
• Children with severely restricted diets 

References

  1. A randomized controlled trial of nurse follow-up clinics: do they help patients and do they free up consultants' time?.Gradwell C. Thomas KS. English JS. Williams HC. British Journal of Dermatology. 147(3):513-7, 2002 Sep.
  2. Atopic eczema in children. NICE Clinical guideline Dec 2007 (accessed May 2014) http://guidance.nice.org.uk/CG57
  3. SafeRx Eczema in children 2012 http://www.saferx.co.nz/full/eczema.pdf
  4. Greater Auckland Integrated Health Network Pathways for primary care http://www.healthpointpathways.co.nz/northern/
  5. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Huang JT, Abrams M, Tlougan B, Rademaker A, Paller AS. Pediatrics 2009;123:e808-e814.
  6. Efficacy and safety of sodium hypochlorite (bleach) baths in patients with moderate to severe atopic dermatitis in Malaysia. Wong S, Ng TG, Baba R. J of Dermatol 2013;40:874-880
  7. Preventing eczema with topical corticosteroids or tacrolimus: which is best? HC Williams. British Journal of Dermatology 2011 164; 231-233
  8. Improved emollient use reduces atopic eczema symptoms and is cost neutral in infants. JM Mason, J Carr, C Buckley et al. BMC Dermatol 2013 13:7
  9. Treatment of patients with atopic dermatitis using wet-wrap dressings with diluted steroid and/or emollients. AP Oranje, ACA Devilliers, B Kunz et al. J Euro Acad Dematol and Venereol 2006; 20: 1277-1286

Document last reviewed: June 2014

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