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February 2008: Use a stepped care approach for atopic eczema in children

What is the role of allergy in atopic eczema?

When should topical steroids be used?

How can infected eczema be treated?

What is the role of allergy in atopic eczema?

When should topical steroids be used?

How can infected eczema be treated?

Childhood atopic eczema is a common condition. a recent UK study reported a lifetime prevalence of 23% in 12 year olds1 and eczema accounts for around one in 30 GP consultations.2

Although 80% of cases of atopic eczema seen in primary care are mild, the severity of the eczema may not be directly correlated with its impact on quality of life.

NICE has recently published a guideline on managing atopic eczema in children under 12 years.3 It provides recommendations on:

• Diagnosis and assessment of the impact of the condition
• Management during and between flares
• Information and education for children, parents and carers.

Diagnosis and assessment

At each consultation, GPs should assess the severity of the eczema and enquire about the child's quality of life (see table 1, attached).

It is important to identify and then eliminate, or treat, trigger factors as these may exacerbate the condition. Trigger factors include: irritants, for example soaps and detergents, skin infections, contact allergens, food and inhalant allergens.

GPs should consider food allergy in children with atopic eczema who have shown a previous immediate reaction to food, or in young children with moderate or severe atopic eczema that has been difficult to control, especially if associated with colic, vomiting, altered bowel habit or failure to thrive.

The guideline development group found no evidence to support the use of high street or internet allergy tests in managing atopic eczema. Allergy testing is a highly specialised and complex field, and high street allergy tests may produce spurious results, leading to unnecessary and potentially harmful dietary changes.

Parents should be reassured that most children with mild atopic eczema and no other signs of food allergy do not need clinical testing for allergies.


Atopic eczema in children should be managed using a stepped approach. Emollients should always be used, even when there is no evidence of active eczema. Other treatments should be adjusted according to the severity of symptoms. See figure 1,attached.

Treatment should be tailored to the patient and both children and parents should be involved in making decisions.


Emollients should be unperfumed and used daily for moisturising, washing and bathing. A range should be offered and the choice should be made by the patient. More than one product may be required.

GPs should prescribe 250-500g per week of leave-on emollients and recommend they are available at the child's nursery or school.

Topical corticosteroids

The strength of topical corticosteroid used should be based on the severity and location of the eczema (see figure 1,attached).

Only mild topical steroids should be used on the face and neck. However, moderate topical steroids can be used for three to five days for severe flares.

For other vulnerable sites, such as the axillae and groin, moderate or potent topical steroids should only be used for 7-14 days to treat flares.

Very potent topical steroids should not be used in children without specialist advice.


Oral antihistamines are not indicated in routine management. However, they may be useful for children with severe eczema, or if there is severe itching or urticaria.

Occlusive dressings

Whole body occlusive dressings, including wet wraps, are not a first-line therapy and should only be introduced by a healthcare professional trained in their use.

Bacterial infection

Flares are often caused by infection. Children and their parents should be taught how to recognise symptoms and signs of bacterial infection and what to do if these occur.

Symptoms and signs include: weeping, pustules, crusts, atopic eczema failing to respond to therapy, rapidly worsening atopic eczema, fever and malaise.

See table 2, attached, for recommended treatments.

Eczema herpeticum

Eczema herpeticum is a potentially life-threatening condition in which eczema is infected with the herpes simplex virus. Signs include:

• Areas of rapidly worsening, painful eczema
• Clustered blisters consistent with early-stage cold sores
• Punched-out erosions (circular, depressed, ulcerated lesions), usually 1–3mm in size and uniform in appearance (these may coalesce to form larger areas of erosion with crusting)

• Fever, lethargy or distress.

Parents and carers should be told to seek medical advice as soon as possible if these signs develop.

GPs should begin treatment with systemic aciclovir immediately (even in the case of localised infection) and arrange same-day referral to a dermatologist. If secondary bacterial infection is also suspected, treatment with appropriate systemic antibiotics should be started.

If eczema herpeticum involves the skin around the eyes, the child should be immediately referred to an ophthalmologist as well.


See table 3, attached, for the NICE recommendations for referral to a specialist dermatology service.


The NICE guideline emphasises the importance of patient and parent education. This should include:

• How much of the treatments to use
• How often to apply them
• When and how to adjust treatment
• How to treat infected eczema.

GPs should give written advice and practical demonstrations. At each consultation, GPs should enquire about compliance and address any problems.

Key points Table 1: Holistic assessment of atopic eczema in children Table 2: Treatment of bacterial infections Table 3: Indications for referral Useful information

Atopic eczema in children is available in several forms on the NICE website. The full guideline gives details of the methods and the evidence used to develop the guidance and the NICE guideline provides a summary. There is also a quick reference guide for clinicians and a version of the guideline for parents and carers


Dr Sarah Purdy
GP, Bristol, and consultant senior lecturer in primary healthcare, University of Bristol, on behalf of the NICE guideline development group for atopic eczema in children

Eczema herpeticum Figure 1: Stepped-care plan for atopic eczema in children (part 1 of 2) Figure 1: Stepped-care plan for atopic eczema in children (part 2 of 2)

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