Eczema (atopic dermatitis)

Key points

• Children with eczema need optimal everyday skin management regardless of how their skin looks.
• Topical steroids are safe and effective when used correctly and are essential to treat eczema flares; they are applied generously, with no need to use them sparingly or take regular breaks during flare treatment.
• Caregivers should be taught everyday skin care, correct use of topical medicines, trigger avoidance and how to recognise a flare or skin infection.
• Every child with eczema should receive a home eczema management plan, including steps to manage a flare.
• Eczema herpeticum needs prompt antiviral treatment, with urgent ophthalmology review if the periorbital area is involved.

Overview

This Royal Children's Hospital Melbourne guideline covers the assessment and management of eczema (atopic dermatitis) in children. Eczema is a chronic inflammatory skin disease with dry, itchy skin that affects 30% of children and often develops before 12 months of age; there is no cure, but it can be well controlled with optimal everyday skin care and correct treatment of flares.

Assessment

In infants under 18 months the cheeks, scalp and extensor surfaces are most often affected; older children usually have flexural dermatitis. History covers symptoms such as poor sleep, itch and poor feeding, triggers, treatments used, previous skin infections, atopy and the impact on quality of life. Poor growth, persistent diarrhoea or recurrent infections should prompt consideration of immunodeficiency or micronutrient deficiency, and a new itchy rash in several family members of scabies. Severity is graded as clear, mild, moderate or severe; EASI and CDLQI can be used. Signs of infection include crusted, vesicular, pustular or weeping lesions, fever and malaise. Tests are not usually required; skin swabs may help in severe flares or recurrent or non-responding infection.

Everyday skin care

A thick, plain moisturising cream with high oil and low water content is applied generously top-to-toe twice a day, including after bathing, taken from the tub with a spatula or spoon. Products with fragrance, alcohol, sodium lauryl sulfate or plant or food ingredients are avoided. Daily lukewarm baths (below 31°C) with soap-free cleansers are recommended; soap and shampoo are not used. Allergy testing is usually not required and restrictive diets are usually not helpful. Common triggers are overheating, dry skin, irritants and infection.

Treating flares and infection

Topical steroids are applied once or twice daily until the skin is completely clear, may be used on broken or infected skin, are dosed by the fingertip unit (FTU) method and are followed by moisturiser. For the face and groin, hydrocortisone 1% is used for mild to moderate flares; for the body, methylprednisolone aceponate 0.1% for mild to moderate and mometasone furoate 0.1% for severe flares. Pimecrolimus 1% is a second-line option for sensitive areas in children over 3 months. Wet dressings are applied 1-4 times daily for at least 3 days with every flare, and bleach baths can be used daily during flares. Bacterial infection (Staphylococcus aureus, Streptococcus pyogenes) is treated with antibiotics after gently removing crusts.

Frequently asked questions

Do topical steroids thin the skin?

When used as per guidelines, they do not cause atrophy, hypopigmentation, hypertrichosis, osteoporosis, purpura or telangiectasia; rare complications have been reported with prolonged and excessive use of potent topical steroids.

Should foods be removed from the diet?

Restrictive diets are usually not helpful, and parents should seek advice from a dermatologist or general paediatrician before eliminating foods.

When is specialist input needed?

The local paediatric team should be considered for eczema herpeticum, severe bacterial infection, moderate or severe eczema not responding to correct treatment for 2 weeks or more, severe eczema under 12 months, poor feeding, poor sleep or failure to thrive; dermatology is consulted when chronic eczema is not controlled despite optimised topical therapy.

Source

The Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Eczema. Last updated January 2024. Endorsed by the Paediatric Improvement Collaborative (PIC). Summary prepared by Medpresso from the original guideline; it is not a substitute for the full text or for medical advice.