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Clinical Practice Guidelines

RCH > Health Professionals > Clinical Practice Guidelines > Eczema

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Eczema
About Clinical Practice
Guidelines

CPG index

Nursing Guidelines

Paediatric Improvement See also

Collaborative Cellulitis and other bacterial skin infections
Nappy rash
Parent resources

Retrieval services Key points

CPG Committee Calendar 1. Children with eczema require optimal everyday skin management regardless of the appearance of their skin
2. Topical steroids are safe and effective when used correctly, and are essential to the treatment of eczema flares
CPG information
3. Caregivers should be educated on how to provide their child with optimal everyday skin management, use topical medicines correctly, avoid
Other resources triggers and identify signs of an eczema flare or skin infection
4. All children with eczema should be provided with a home eczema management plan, including steps to manage an eczema flare
CPG feedback

Background
Eczema (atopic dermatitis) is a chronic inflammatory skin disease characterised by dry, itchy skin
Eczema affects 30% of children, and often develops before 12 months of age. Some children develop lifelong eczema
The distribution, severity and irritation caused by eczema may acutely worsen, this is termed an eczema flare
Educating caregivers about eczema and its management is key in reducing the frequency and severity of eczema flares
Eczema flares are commonly due to inadequate caregiver education on eczema management, and triggers such as skin infection, irritant
exposure and heat

Assessment
History
Onset, pattern and severity of eczema
In infants <18 months, the cheeks, scalp and extensor surfaces are most often affected
In older children, eczema commonly presents as flexural dermatitis eg antecubital fossae, popliteal fossae, neck, front of ankles,
periorbital area

Associated symptoms eg reduced sleep, itch, irritability, poor feeding, failure to thrive
Identified triggers
Current and previous eczema treatments, including frequency of treatments, volume of creams used, dietary manipulation, complementary
treatments
Previous skin infections eg staph aureus, varicella zoster, herpes simplex virus
Personal and family history of atopy
Impact of eczema on child and family quality of life eg number of days of missed school/work, number of hospital admissions
Poor growth, persistent diarrhoea and/or recurrent infections (consider immunodeficiencies, micronutrient deficiency)
New itchy rash affecting multiple family members (consider scabies)

Examination
The type and frequency of eczema treatments depends on eczema severity and the presence/absence of infection

Eczema severity

Clear Normal skin, no evidence of active atopic eczema

Mild Areas of dry skin, infrequent itching (with or without small areas of redness)

Moderate Areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening)

Severe Widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding,
oozing, cracking and alteration of pigmentation)

Scoring tools can be used to obtain an objective measure of severity and response to treatment, Eczema Area and Severity Index (EASI) or impact on
quality of life Children’s Dermatology Life Quality Index (CDLQI)

Infected eczema

Cutaneous features include increasing itch, crusted, vesicular, satellite, pustular, erosive, tender, scabbed or weeping lesions on eczematous
skin
Systemic features include fever and malaise

Eczema bacterial infection Eczema herpeticum Eczema coxsackium

Itchy yellowish crusts, weeping, pustules, Painful clustered blisters, punched-out Vesiculobullous rash with brownish
folliculitis erosions discolouration, satellite lesions surrounding
areas of dermatitis

Discoid (nummular) eczema

A variant type of eczema characterised by coin-shaped, pruritic, inflamed plaques and multiple erythematous papules. Generally develops in
later childhood, and is more common in people with dark skin and males
Associated with increased persistence and treatment resistance, often requiring extended treatment courses with potent steroids. Differential
diagnoses include psoriasis, tinea corporis and impetigo. Bacterial and fungal cultures may be useful to clarify the diagnosis

Management
Investigations
Tests are not usually required
If there are concerns of severe flare (eg requiring hospitalisation), recurrent skin infections or an infection that does not respond to treatment,
skin swabs (bacterial and/or viral) of the lesions may be useful to direct antimicrobial therapy

Treatment
There is no cure for eczema, but it can be well controlled with optimal everyday skin management and correct treatment of eczema flares
All children with eczema should be provided with a home eczema management plan and a demonstration of how to correctly apply topical treatments

Eczema management

Optimal everyday skin management

Moisturisers

Apply moisturisers generously top-to-toe twice per day, including after bathing
Reapply if skin feels dry, after hand washing or face wiping
A thick, plain moisturising cream, with high oil and low water content should be used
Avoid moisturisers containing fragrance, alcohol, sodium lauryl sulfate, plant or food products (eg cow or goat milk, vegetable, nut or olive oils)
as these may disrupt the skin barrier and sensitise the skin
Avoid contaminating the moisturiser with bacteria from the hands. Use a spatula or spoon to remove cream from tub and place it onto clean
paper. Moisturiser from the paper can then be applied by hand to the child’s skin

Bathing

Daily bathing (where water quality/access allows) aids to reduce the bacterial skin load and reduce the risk of infection
Baths and showers should be kept luke-warm (<31°C)
A capful of bath oil may be added to bath water, advise parents this increases risk of child slipping, and direct supervision is always required
Do not use soap or shampoo. Use soap-free skin cleansers that will not irritate the skin
Avoid sharing towels between family members
Avoid wash/cleanser products or hair washing products that contain methylisothiazolinone (MI) or methylchloroisothiazolinone (MCI) and nappy
wipes that contain benzalkonium chloride, as these can cause contact dermatitis

General considerations

Food allergies: Allergy testing is usually not required. Restrictive diets are usually not helpful, and parents should seek advice from a
dermatologist or general paediatrician before eliminating foods from the diet
Antihistamines: Non-sedating antihistamines do not improve eczema itch, but may be considered if there is concomitant urticaria or allergic
rhinitis

Common reasons for eczema treatments not being effective include:

Inadequate education regarding eczema and the correct use of eczema treatments
Inadequate application of moisturisers, topical steroids and/or wet dressings
Ongoing exposure to eczema triggers
Delayed use of eczema flare treatments eg topical steroids and wet dressings
Inability to identify and treat skin infections
MRSA bacterial infection

Minimising common eczema flare triggers

Overheating Dry skin Irritants Infection/Inflammation

Keep baths luke-warm
Keep the home and car cool
Avoid air blowing heaters & low
humidity environments
Use light bed coverings &
pyjamas (eg cotton pyjamas)
Avoid woollen underlays, plastic
mattress protectors, sleeping
bags, hot water bottles
Avoid thick and multiple layers of
clothing
Avoid (alcohol) nappy wipes. Use
cloth with water & bath oil
Bathe or shower with bath oil
immediately after swimming in
chlorinated pool
Use a non-perfumed clothes Wash hands before applying
detergent eczema treatments
Avoid contamination of
Remove clothing tags, avoid
moisturisers/creams by using a
rough & prickly fabrics
spatula to remove moisturiser from
Avoid dummies, drooling can container, do not touch ends of
cause irritation tubes
Apply barrier cream to the perioral
Seek medical review early if
area when the infant is dribbling
concerns of infection not
responding to prescribed treatment
Manage anxiety or behaviours
that promote scratching
Keep nails short, use mittens in
infants

Eczema flare management

Steroids

Topical steroids (see additional resources below) are required once or twice daily until the skin is completely clear to reduce skin inflammation.
They can be applied to broken and infected skin
There is no requirement to use steroids ‘sparingly’ or for regular breaks from steroids during treatment for eczema flares. Steroids should be
applied generously followed by moisturiser. Steroid cream dosage for application be calculated using the " Fingertip Unit" method

Patient’s age Fingertip Units per body area

Face and neck Arm and hand Leg and foot Anterior chest and Back and buttocks
abdomen

3-12 months 1 1 1½ 1 1½

>1-3 years 1½ 1½ 2 2 3

>3-6 years 1½ 2 3 3 3½

>6-10 years 2 2½ 4½ 3½ 5

>10 years 2½ 4 8 8 7

Topical steroids do not cause atrophy, hypopigmentation, hypertrichosis, osteoporosis, purpura or telangiectasia when used as per guidelines.
Rare complications such as striae, adrenal suppression and ophthalmological disease have been reported with prolonged and excessive use
of potent topical steroids
Mild to moderate facial eczema should be treated with low potency steroids to avoid chemical skin irritation. Topical pimecrolimus is a non-
steroid alternative that may be used as a second line treatment for moderate eczema in sensitive areas such the face, eyelids and groin

Moisturisers

Continue moisturiser at least twice a day, apply to wet skin after bathing and reapply whenever skin feels dry
Apply the moisturiser on top of other topical medicines such as steroids

Wet dressings

Wet dressings assist to return moisture to the skin, protect from infection and further trauma, and help to reduce irritation and itch
Dressings should be applied with every flare 1-4 times daily for at least 3 days. More frequent dressings and/or longer treatment may be
required in severe eczema
May be used in eczematous skin infections, in addition to antimicrobial treatment
Parents must be educated on how to correctly make and apply wet dressings
Cool compresses (cloth or towel soaked in water and/or bath oil) can used on the face to provide immediate relief of itch
Hospital in the home services may be available in some areas to assist and educate caregivers

Bathing

Bleach baths can be used daily with every flare to reduce the bacterial skin load
The child’s face and head should be wet during the bath, but not submerged
Do not rinse after bathing

Eczematous skin infections

Broken eczematous skin has a high-risk of bacterial and/or viral skin infections

Bacterial infections

Common causative organisms include Staphylococcus aureus (consider MRSA in high-risk groups or if not responding to first-line antibiotics)
and Streptococcus pyogenes
Remove crusted lesions by wiping them gently with a cloth whilst soaking in the bath. Only apply topical steroids and moisturisers after the
crusts are removed
Treat with antibiotics. Children who have systemic features or severe infections may require admission and intravenous antibiotics

Viral infections

Common causes include herpes simplex, coxsackievirus, molluscum contagiosum and varicella zoster viruses
Often co-exist with bacterial infection, consider if infected eczema is not responding to antibiotic management
Herpes simplex infection (eczema herpeticum) requires prompt initiation of antiviral treatment. Intravenous antiviral treatment may be required
in severe infections. Urgent Ophthalmology review is required if the infection affects the periorbital area

Recurrent infections

Consider patient and family Staphylococcus aureus decolonisation

Antiseptic preparations may reduce skin bacterial load eg bleach baths, triclosan skin cleanser, chlorhexidine skin wash

Consider consultation with local paediatric team when

Eczema herpeticum or severe bacterial eczematous skin infections
Moderate or severe eczema not responding to treatment despite compliance with correct treatment for 2 weeks or more
Concern that the child’s carers are not able to provide appropriate eczema treatments and are unable to access outpatient supports
Severe eczema in a child <12 months old
Poor feeding, poor sleep, failure to thrive
Suspicion of systemic disease eg immunodeficiency or micronutrient deficiency
Suspicion of concurrent severe allergies eg recurrent urticarial, systemic flushing, periorbital eczema, eczema limited to exposed skin - limbs

Consider consultation with local dermatology team when

Chronic eczema not controlled with optimised topical therapies and everyday skin management, for consideration of systemic therapies

Additional notes
ASCIA Eczema Action Plan
ASCIA Eczema e learning
Eczema Area and Severity Index (EASI)
Skin Deep - Eczema photo gallery in a range of skin tones

Parent information & resources

RCH Kids Health Information: Eczema
RCH Kids Health Information: Bleach baths
RCH Knowing your child’s eczema – parent resources page (English, Vietnamese, Mandarin)
RCH Eczema triggers identification questionnaire
The Eczema Association of Australasia
ASCIA Eczema and food allergy
Nip allergies in the bub - Eczema
AMH Fingertip units

Additional resources
Medication Information
Provide children with prescriptions for multiple quantities and repeats (PBS authority where applicable) of each medication

Type Example medications Dosing

Topical steroids For sensitive areas eg face, groin Frequency

Mild to moderate flare: Use mild potency steroid eg Hydrocortisone: Apply twice a day until
Hydrocortisone 1% ointment or cream symptoms resolved
Severe flare: Use moderate potency steroid eg Mometasone and methylprednisolone:
Methylprednisolone aceponate 0.1% ointment or cream for Apply once a day until symptoms
short term use only, max 3-5 days on face/neck, 7-14 days resolved
on groin
Form
For body
Ointments are preferred to creams for
Mild to moderate flare: Use moderate potency steroid eg their emollient effects
Methylprednisolone aceponate 0.1% fatty ointment, ointment Lotions are best used for hairy areas eg
or cream scalp
Severe flare: Use potent steroid eg Mometasone furoate
0.1% ointment or cream
Very potent topical steroids eg Betamethasone dipropionate
0.05% should not be used without dermatological advice

Topical calcineurin For sensitive areas eg face, groin Frequency

inhibitor
Mild to moderate flare: Pimecrolimus 1% cream can be used Apply twice a day until symptoms
as second-line treatment in children >3 months resolved
Treatment courses should be limited to 6
weeks (3 weeks if 3-23 months age)

Last updated January 2024

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