Eczema in children

Initial management advice

Thank you for referring your patient to the paediatric dermatology clinic. This information is to provide treatment advice, either as optimisation of initial management in the community, or whilst waiting for an appointment.

If you have not previously prescribed adequate or sufficient treatment, your referral may be rejected in order to manage demand for the outpatient clinic and ensure we are only seeing patients who are difficult to control in the community.

It is important to explain the aim of treatment is control rather than cure: eczema is a chronic condition which will recur if treatment is insufficient or stopped too early. Regular use of emollient and maintenance use of topical steroid (e.g. once or twice per week even when skin is less inflamed) should be used to prevent recurrence.

Emollient

Apply emollient ointment (hydromol or similar) in the morning and throughout the day if needed, all over the body gently and in the direction of hair growth. If the child is at school or cannot tolerate greasy textures, a cream such as diprobase or similar may be used instead, but would need to be applied more frequently. Children with widespread active eczema may require 2 x 500g emollient to be prescribed per month.

Bathing

Children should be bathed once daily, which is especially important if their skin is infected or prone to infection. An emollient soap substitute can be used for washing, such as hydromol ointment or Dermol 500 lotion. Caregivers may choose to buy emollient bath additives if they wish.

Topical steroid

Adequate topical steroid application is crucial in the management of eczema. Your patient may have used a topical steroid which is too mild, or not continued the topical steroid for long enough to induce remission of eczema. If the steroid is stopped abruptly, the eczema may recur.

In view of this, we recommend applying topical steroid of adequate strength to control the eczema for long enough to ensure the skin has improved, then gradually reducing the frequency of application. Topical steroid should be applied once daily (at a different time to the emollient) to all active areas of eczema until the skin is no longer itchy, red or scaly, and then reduced to alternate days for two weeks before stopping. If the child is experiencing very frequent flares (more than one a month) then they can continue to use the topical steroid twice-weekly longer term after gaining control of the eczema as above.

Strength of topical steroid

1% hydrocortisone for facial eczema or mild eczema on the body of a baby: apply once
daily until symptoms have improved and then gradually reduce to alternate days and then twice-weekly as maintenance if required. Generally, 5 days maximum on the face as a once daily application is recommended, and then reducing down. Eumovate ointment moderate strength steroid (Betnovate RD 0.025% as alternative if Eumovate unavailable) for eczema on the body of a baby or child: apply once daily for up to two weeks and then reduce potency to hydrocortisone 1% ointment as above. Betnovate 0.1% ointment may be required in older children with particularly stubborn eczema not responsive to the weaker topical steroids. Dermovate is not recommended for use on children without supervision of a dermatologist.

Calcineurin inhibitors (topical pimecrolimus and tacrolimus)

Tacrolimus ointment is licensed in children between 2-15 years at a strength of 0.03% and in those age 16 and above at a strength of 0.1%. Pimecrolimus cream is licensed from age 3 months. These are best used as maintenance treatment after initial control with a topical steroid has been gained, to reduce the quantity of topical steroid being applied in chronic eczema. Tacrolimus can be used twice daily for the first 2 weeks and then reduced to once daily for ongoing maintenance. Pimecrolimus can be used once or twice daily. It should be applied at night and patients warned to protect their skin from the sun and to stop if any skin infections.

Infected eczema

Atopic eczema can become secondarily infected, but antibiotics are not a primary treatment for eczema. If your patient is shivery, feverish or unwell, or has areas of yellow crusting or weeping then a bacterial swab followed by a course of oral antibiotics should be considered. In this case, eczema should still be managed with adequate topical steroid, even when the patient is on the antibiotics.

Eczema can also become infected with viruses, such as the herpes simplex or coxsackie virus (eczema herpeticum or eczema coxsackium, respectively). Viral swabs should be taken and treatment started as required: secondary care input should be sought if the patient is unwell.

Hand eczema

Stronger steroid such as 0.1% Betnovate may be required for hand eczema in older children. This is best applied at night with cotton glove occlusion.