Clinical Topic A-Z Clinical Speciality

Eczema - atopic

Eczema - atopic
D003876Dermatitis, Atopic
D004485Eczema
Skin and nail
2013-03-01Last revised in March 2013

Eczema - atopic - Summary

Atopic eczema is a chronic, relapsing, itchy skin condition. In infants, atopic eczema primarily involves the face, scalp, and extensor surfaces of the limbs. In children, involvement of the skin creases is more likely. There may be skin dryness, redness, vesicles, scaling, crusting, or thickening (lichenification) if there are chronic changes.

Genetic and environmental factors may have a role in the development of atopic eczema.

Atopic eczema is present in about 80% of children where both parents are affected, and in 60% if only one parent is affected. A personal or family history of atopy (hay fever or asthma) may be present.

Environmental factors include exposure to pets, house-dust mites, pollen, and food allergens (such as cow’s milk or egg).

Around 80% of cases occur before 5 years of age, with a high incidence of onset in the first year of life.

Complications of atopic eczema include:

Infection — bacterial infection with Staphylococcus aureus, herpes simplex virus infection (may be widespread if eczema herpeticum), or superficial fungal infection.

Psychosocial issues — such as missed school, bullying, disturbed sleep, reduced self-confidence.

Atopic eczema typically has intermittent flares, with a tendency to gradual improvement in adult life.

Self-care advice should be given to the person or carers to avoid:

Scratching eczema, if possible, and to keep nails short.

Known trigger factors, such as soaps and detergents (use emollients instead).

Flares can usually be controlled with emollient and/or topical steroid treatment:

Emollients are the mainstay of treatment for mild flares of atopic eczema. They should be prescribed in generous amounts and frequent and liberal use advised, even when the skin is clear.

The prescription of topical steroid cream or ointment for red, inflamed skin should be considered. Use of the lowest potency and amount of topical corticosteroid necessary to control symptoms should be advised, depending on the severity of the flare. Steroid treatment should be continued for 48 hours after the flare has been controlled.

A one-month trial of non-sedating antihistamines should be considered if there is persistent, severe itch or urticaria.

A short course of oral corticosteroids (with oral antibiotics if there are signs of infection) should be considered if there is severe, extensive eczema.

Secondary bacterial infection should be considered if eczema is weeping, crusted, or there are pustules, with fever or malaise. If there is:

Extensive, infective eczema: a swab of the skin should be taken before starting oral antibiotics.

Localized infection: a topical antibiotic should be considered.

Referral to a dermatologist should be considered if:

The diagnosis is uncertain.

Eczema is not controlled with current treatment.

There is recurrent secondary infection.

Treatment advice is needed (such as bandaging techniques).

Referral to an immunologist, paediatrician, or dermatologist should be considered if a food allergy trigger is suspected and the expertise to diagnose and manage food allergy is not available in primary care.

The person should be admitted to hospital urgently if eczema herpeticum is suspected (rapidly worsening, painful eczema; clustered blisters; punched out erosions).

Have I got the right topic?

1months3060monthsBoth

This CKS topic is based on the Clinical Guideline Management of atopic eczema in children from birth up to the age of 12 years, produced by the National Collaborating Centre for Women's and Children's Health, and published by the National Institute for Health and Care Excellence [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007].

This CKS topic covers the assessment and management of atopic eczema in people of all ages in primary care.

This CKS topic does not cover the detailed use of second-line treatments for atopic eczema that can be managed by a healthcare professional with specialist expertise (for example a GP with a specialist interest in dermatology).

There are separate CKS topics on Angio-oedema and anaphylaxis, Asthma, Conjunctivitis - allergic, Dermatitis - contact, Seborrhoeic dermatitis, and Urticaria.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.

CKS gratefully acknowledges the contribution of the British Association of Dermatologists in the development of this topic.

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in March 2013

March 2013 — reviewed. A literature search was conducted in January 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No major changes to clinical recommendations have been made; however, a link to the NICE guideline Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community settings (pdf) [NICE, 2011] has been provided for information on how to diagnose and manage a suspected food allergy in primary care.

Previous changes

June 2012 - minor update. Minor typographical error corrected.

January 2012 — minor update. Strength and generic name of Dermovate® corrected in prescribing information. Issued in February 2012.

August 2011 — minor update. Clarified the recommendation on when to swab people with eczema. Issued in September 2011.

July 2011 — minor update. Typographical errors corrected in the sections on treatment of moderate flares of eczema and advice for people using emollients and topical corticosteroids. Issued in July 2011.

April 2011 — minor update. Additional recommendations from the SIGN guideline Management of atopic eczema in primary care have been incorporated into this topic. Issued in June 2011.

October 2010 — technical update. The management section of this topic has been simplified to improve clarity and navigation. There have been no changes to the clinical content or meaning of the recommendations.

October 2010 — minor update. Chlorphenamine is no longer licensed for the treatment of pruritus. Text and prescriptions amended to reflect this. Issued in October 2010.

October 2008 — minor update to usage instructions for diprobase cream. Issued in November 2008.

March to July 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

Prescriptions for emollients and topical corticosteroids have been reduced in scope to only include the most commonly prescribed products, as it is not feasible to include all available products, or helpful to the prescriber. Prescriptions for sedating antihistamines, non-sedating antihistamines, and topical antibiotics have been added in accordance with NICE recommendations.

September 2008 — minor update to text. Issued in September 2008.

January 2006 — minor update to include prescriptions for Hydromol® emollient products. Issued in February 2006.

October 2005 — minor technical update. Issued in November 2005.

February 2005 — minor formatting update. Desoximetasone 0.05% oily cream discontinued and prescriptions removed.

July 2004 — written. Validated in September 2004 and issued in November 2004.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines published since 1 January 2013.

HTAs (Health Technology Assessments)

No new HTAs published since 1 January 2013.

Economic appraisals

No new economic appraisals relevant to England since 1 January 2013.

Systematic reviews and meta-analyses

Systematic reviews published since the last revision of this topic:

Bamford, J.T.M., Ray, S., Musekiwa, A., et al. (2013) Oral evening primrose oil and borage oil for eczema (Cochrane Review). The Cochrane Library. Issue 4. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]

Foolad, N., Brezinski, E.A., Chase, E.P. and Armstrong, A.W. (2013) Effect of nutrient supplementation on atopic dermatitis in children: a systematic review of probiotics, prebiotics, formula, and fatty acids. JAMA Dermatology 149(3), 350-355. [Abstract]

Gu, S., Yang, A.W.H., Xue, C.C.L., et al. (2013) Chinese herbal medicine for atopic eczema (Cochrane Review). The Cochrane Library. Issue 9. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]

Pelucchi, C., Galeone, C., Bach, J.F., et al. (2013) Pet exposure and risk of atopic dermatitis at the pediatric age: a meta-analysis of birth cohort studies. Journal of Allergy and Clinical Immunology 132(3), 616-622.e7. [Abstract]

Tan, H.Y., Zhang, A.L., Chen, D., et al. (2013) Chinese herbal medicine for atopic dermatitis: a systematic review. Journal of the American Academy of Dermatology 69(2), 295-304. [Abstract]

Primary evidence

No new randomized controlled trials published in the major journals since 1 January 2013.

New policies

No new national policies or guidelines since 1 January 2013.

New safety alerts

No new safety alerts since 1 January 2013.

Changes in product availability

No changes in product availability since 1 January 2013.

Goals and outcome measures

Goals

To support primary healthcare professionals:

To treat atopic eczema in primary care with appropriate treatments

To identify factors triggering atopic eczema

To give general self-care advice and specific advice on the use of emollients and topical corticosteroids

To appropriately refer people who require further assessment and treatment by a specialist

Background information

Definition

What is it?

Atopic eczema is a chronic, relapsing, itchy skin condition [NICE, 2007; Peate, 2011; DermNet NZ, 2013].

People with atopic eczema have a reduction in the lipid barrier of the skin; this leads to an increase in water loss and a tendency towards dry skin [NICE, 2007].

The pathophysiology of atopic eczema is a complex interaction of susceptible genes, environmental triggers, defects in the skin barrier, and immunologic responses [Akdis et al, 2006; Peate, 2011].

Causes

What causes it?

There is no known single cause for atopic eczema [DermNet NZ, 2012a]; however:

Atopic eczema occurs in genetically susceptible individuals when exposed to environmental irritants or allergens. It may be exacerbated, but not caused, by trigger factors such as stress or hormonal changes (in women). Premenstrual flares of atopic eczema occur in 30% of women, and pregnancy can adversely affect eczema in up to 50% of women [Beltrani and Boguneiwicz, 2003].

Atopic eczema often has a genetic component, but a specific genetic cause has not been identified [Akdis et al, 2006]. It is present in about 80% of children where both parents are affected, and in 60% if only one parent is affected [Uehara and Kimura, 1993]. More severe early disease is seen in children with atopic parents [Akdis et al, 2006].

Environmental factors also have a role in the development of atopic eczema [Akdis et al, 2006].

Exposure to pets, house-dust mites, and pollen have been shown to increase the risk of atopic eczema.

Food allergens (often cow's milk or eggs) are associated with atopic eczema and are related to disease severity [NICE, 2011].

Prevalence

How common is it?

Atopic eczema accounts for 30% of all dermatological consultations in general practice [Holden and Parish, 1998], and the prevalence is increasing [Shamssain, 2007; Sehra et al, 2008].

Estimates vary due to the different populations examined, but figures suggest a prevalence of around 15–20% in children and 2–10% in adults [Primary Care Dermatology Society and BAD, 2010; Baron et al, 2012].

There is no difference in prevalence based on sex and ethnicity [NICE, 2007; Osman et al, 2007].

Around 80% of cases occur before 5 years of age [Wüthrich, 1996], with a high incidence of onset in the first year of life [NICE, 2007].

Complications

What are the complications?

Infection [NICE, 2007]:

Bacterial infection with Staphylococcus aureus, which may present as typical impetigo or as worsening of eczema with increased redness, oozing, and crusting.

Herpes simplex infection, indicated by grouped vesicles and punched-out erosions. Disseminated herpes simplex virus infection (eczema herpeticum) presents with widespread lesions that may coalesce into large, denuded, bleeding areas that can extend over the entire body.

Superficial fungal infections are more common in people with atopic eczema.

Psychosocial problems [NICE, 2007]:

Atopic eczema causes considerable distress.

Preschool children with atopic eczema have higher rates of behavioural problems, fearfulness, and dependency on their parents, than unaffected children.

School children with atopic eczema have problems including time away from school, impaired performance, social restrictions, teasing, and bullying.

Atopic eczema can be associated with poor self-image and self-confidence that can impair social development. Among children with moderate-to-severe eczema attending outpatient departments, psychological problems are double that of school children without eczema.

Sleep disturbance is a major problem for people with atopic eczema and their families [Simpson, 2010].

Erythroderma [DermNet NZ, 2012b]:

Erythroderma (a generalised redness of the skin) is a severe skin condition that can result in complications such as dehydration, heart failure, infection, and death.

Erythrodermic eczema usually occurs in people with worsening or unstable eczema. Skin infection (requiring treatment with intravenous antibiotics) is common in people with erythrodermic eczema.

Eye abnormalities [DermNet NZ, 2012b]:

Conjunctival irritation is common.

Keratoconus (conical-shaped eyeball) is a rare condition which is occasionally associated with atopic eczema and can lead to marked visual disturbances. It is due to degeneration and weakening of the cornea, resulting in the front of the eye being pushed outwards due to the normal pressure within the eyeball.

Cataracts can occur with severe atopic eczema, usually in people aged 15–25 years of age. They are almost always bilateral and may have a characteristic appearance on eye examination which helps distinguish them from other causes of cataract.

Retinal detachment is rarely associated with atopic eczema.

Prognosis

What is the prognosis?

Atopic eczema is typically an episodic disease of flares (exacerbations, which may occur as frequently as two or three times each month) and remissions. In severe cases disease activity may be continuous.

Atopic eczema runs a relapsing course with a tendency to gradual improvement in adult life.

A cohort study (n = 571) of children with atopic eczema at 7 years of age found that 53% would be clear of eczema by 11 years of age and 65% by 16 years of age, after adjusting for recurrences in teenage years and adulthood.

There is some evidence that the prognosis of atopic eczema is worse when the onset is early, and in children with associated asthma. It is not clear whether the prognosis is better in children with mild disease.

[NICE, 2007]

Diagnosis and assessment

Diagnosis and assessment of atopic eczema

Diagnosis

How should I diagnose atopic eczema?

Ask whether the rash is itchy: the diagnosis is unlikely to be atopic eczema if there is no itch.

Ask about the onset and natural history of the rash: atopic eczema usually starts in infancy and is episodic in nature (see Differential diagnosis if clinical features are atypical).

Ask about a family or personal history of atopy: allergic rhinitis and asthma are associated with atopic eczema.

Examine the rash: the person's age and the duration of the rash will influence its distribution and appearance.

Infancy: eczema primarily involves the face, the scalp, and the extensor surfaces of the limbs. The nappy area is usually spared.

Children: longstanding eczema; localization to the flexure of the limbs is more likely.

Adults: flexure involvement with generalized dryness and itching, particularly with exposure to irritants. Eczema on the hands may be the primary manifestation.

Acute eczema (flares): vary in appearance, from poorly demarcated redness to fluid in the skin (vesicles), scaling, or crusting of the skin.

Chronic eczema: affected skin becomes thickened (lichenified) as a result of repeated scratching.

Infected eczema: rapidly worsening eczema that fails to respond to treatment. Infection may be viral, bacterial, or fungal. See Assessing infected eczema.

Investigations are not required to establish the diagnosis of atopic eczema.

The diagnostic criteria for atopic eczema are listed in Diagnostic criteria.

Diagnostic criteria

Diagnostic criteria for atopic eczema in children and adults

Atopic eczema is likely if the following criteria are fulfilled (although other conditions may need to be excluded):

An itchy skin condition (or parental report of scratching) in the last 12 months, plus three or more of the following:

A history of involvement of the skin creases (fronts of elbows, behind knees, fronts of ankles, around neck, or around eyes).

A personal history of asthma or hay fever (or history of atopic disease in a first degree relative if a child is less than 4 years of age).

A history of generally dry skin in the last year.

Onset under the age of 2 years (not used if a child is less than 4 years of age).

Visible flexural eczema (including eczema affecting cheeks or forehead and outer aspects of limbs in children less than 4 years of age).

Note that this criteria apply to all ages, social classes, and ethnic groups. However, in children of Asian, black Caribbean, and black African ethic groups, atopic eczema can affect the extensor surfaces rather than the flexures, and discoid or follicular patterns may be more common.

[Williams et al, 1994; NICE, 2007]

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guidelines Atopic eczema in children published by the National Institute for Health and Care Excellence [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007] and Guidelines for the management of atopic eczema published by the British Association of Dermatology [Primary Care Dermatology Society and BAD, 2010].

Differential diagnosis

What else might it be?

Psoriasis: less itchy, well-circumscribed, reddish, flat-topped plaques with silvery scale, and typically symmetrical. See the CKS topic on Psoriasis.

Allergic contact dermatitis: eczematous rash, at any site related to a topical allergen, in a person of any age. See the CKS topic on Dermatitis - contact.

Seborrhoeic dermatitis: red, sharply marginated lesions with greasy scales; usually confined to areas with sebaceous gland activity (for example ears, beard area, eyebrows, scalp, and nasolabial folds). See the CKS topic on Seborrhoeic dermatitis.

Fungal infection: annular patch or plaque with slightly raised, sometimes scaly, border, and central clearing. See the CKS topics on Fungal skin infection - body and groin, Fungal skin infection - foot, Fungal skin infection - scalp.

Scabies and other infestations should be suspected when there is recent onset of an itchy rash in a family. See the CKS topic on Scabies.

Basis for recommendation

Basis for recommendation

Information on the differential diagnosis of atopic eczema is based on Guidelines for the management of atopic eczema published by the British Association of Dermatology [Primary Care Dermatology Society and BAD, 2010] and expert opinion in a review article [Baron et al, 2012].

Assessing physical severity

How should I assess the physical severity of eczema?

Examine all areas of affected skin and ask about itching. Categorize eczema as:

Clear: normal skin, no evidence of active eczema.

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

Moderate: areas of dry skin, frequent itching and redness (with or without excoriation and localized skin thickening).

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

Consider using validated tools to assess severity. For example, using visual analogue scales (0–10) of the individual's assessment of severity, itch, and sleep loss over the last 3 days and nights, or using the Patient-Oriented Eczema Measure (which can be downloaded from www.nottingham.ac.uk (pdf)).

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], and have been extrapolated to include the management of older children and adults.

An examination of all patches of eczema is needed as differing severity can coexist on the same individual, requiring independent treatment. Physical examination is essential to determine the correct treatment.

The NICE Guideline Development Group could not find any evidence on the usefulness of severity and quality of life measures for guiding treatment decisions in clinical practice. Nevertheless, a structured, validated tool may prompt individuals and families about certain aspects of the condition, thereby improving communication and treatment.

Assessing psychological impact

How should I assess the psychological impact of eczema?

Ask about the effect of eczema on daily activities (school, work, and social life), sleep, and mood. Categorize the impact of eczema on quality of life and psychosocial well-being as:

None: no impact on quality of life.

Mild: little impact on everyday activities, sleep, and psychosocial well-being.

Moderate: moderate impact on everyday activities and psychosocial well-being, and frequently disturbed sleep.

Severe: severe limitation of everyday activities and psychosocial functioning, and loss of sleep every night.

Consider using questionnaires to give an objective measure of quality of life. For example, the Children's Dermatology Life Quality Index (CDLQI) and Adult's Dermatology Life Quality Index (ADLQI), Infant's Dermatitis Quality of Life index (IDQOL), or Dermatitis Family Impact questionnaire (DFI). For more information on quality of life questionnaires, see www.dermatology.org.uk.

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], and have been extrapolated to include the management of older children and adults.

An assessment of quality of life will help influence treatment choices and referral decisions. For example, if the person has only mild physical symptoms but is severely affected psychologically, a referral to secondary care is appropriate.

One survey found that 60% of children with atopic eczema had sleep-related problems. Another survey found that during a flare of atopic eczema an average of five nights of sleep were affected, with an average of two wakings per night [NICE, 2007].

One study found that caring for children with atopic eczema was more stressful for parents than caring for children with type 1 diabetes, with sleep problems, time missed from work, the practical burden, and financial cost being most problematic. Carers often report exhaustion, anxiety, and guilt when questioned about looking after children with atopic eczema [NICE, 2007].

Assessing infected eczema

How should I assess infected eczema?

Rule out eczema herpeticum (which requires urgent admission). Signs of eczema herpeticum are:

Areas of rapidly worsening, painful eczema.

Clustered blisters consistent with early-stage cold sores.

Punched-out erosions (circular, depressed, ulcerated lesions), usually 1–3 mm, that are uniform in appearance (these may coalesce to form larger areas of erosion with crusting).

Possible fever, lethargy, or distress.

Rule out other viral infections such as varicella (chicken pox), molluscum contagiosum, and verrucae vulgaris (viral warts).

Diagnose bacterial infection if the following signs and symptoms are present:

Eczema that is weeping and crusted, or there are pustules and/or surrounding cellulitis with erythema of otherwise normal-looking skin.

Eczema that is rapidly worsening or has failed to respond to treatment.

Fever or malaise.

Consider swabbing lesions for microbiological assessment only if:

There is reason to believe there is involvement of an atypical or resistant pathogen (that is, eczema is failing to respond to antibiotic treatment).

There are extensive areas of infected eczema (a swab should be taken before treatment with an oral antibiotic is commenced).

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], and have been extrapolated to include the management of older children and adults.

The diagnosis of eczema should be made on clinical signs, using the physician's experience. Although there have been several case reports and case series describing infected eczema, these have not provided definitive criteria on which infected eczema can be diagnosed.

It is essential to rule out eczema herpeticum as this disseminated form of the disease can prove fatal, with an estimated mortality rate of 6–10%.

The pathogen involved in infected eczema is usually Staphylococcus aureus, but is sometimes Streptococcus pyogenes. Both present with similar signs, and management is not affected by the presence of one or the other.

S. aureus accounts for up to 90% of the aerobic bacteria found in people with atopic eczema (compared with about 30% in people without atopic eczema) and large bacterial loads are thought to correlate with the clinical severity of the condition.

There is a general consensus, backed by clinical experience, that visibly infected eczema will heal poorly, if at all, without antibiotic treatment.

Swabbing

Following advice from experts, CKS recommends swabbing all people with infected eczema before treatment with an oral antibiotic is started. This will allow for early detection of resistant staphylococcal species (including meticillin resistant Staphylococcus aureus [MRSA]) and beta haemolytic streptococci species, which may influence subsequent management.

Note that this recommendation is not in full agreement with the NICE or SIGN (Scottish Intercollegiate Guidelines Network) guideline development groups, who recommend swabbing only if there is recurrent infection or other reason to believe there is involvement of resistant or atypical organisms [NICE, 2007; SIGN, 2011].

Identifying trigger factors

How should I identify trigger factors?

The majority of people will present with a flare of their eczema, so ask specifically about any changes in diet, stress levels, pets, or irritants. In women, also consider hormonal triggers.

Diet: ask about itch or redness after certain foods (immediately or hours later), diarrhoea, vomiting, and poor weight gain. Consider asking the person to keep a food diary over 4–6 weeks. In infants, also ask about feeding history (weaning, breastfeeding, or bottle feeding).

Irritants: ask about changes in soaps, detergents, and clothing, especially in previously well controlled eczema.

Inhalants: ask about symptoms around pets and pollen, especially in older children and adults with seasonal flares, asthma, or rhinitis, and in children over 3 years of age with facial eczema.

Hormonal: changes in hormone levels can affect the symptoms of atopic eczema in some women. Premenstrual flares of eczema occur in 30% of women, and pregnancy can adversely affect eczema in up to 50% of women.

Most people do not need allergy testing. Advise avoidance of over-the-counter tests (as these are of no proven value).

If a food allergy is suspected, manage in primary care if the expertise and support are available, otherwise, refer to secondary care.

If other types of allergies are suspected, refer to secondary care.

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guidelines Atopic eczema in children and Food allergy in children and young people, published by the National Institute for Health and Care Excellence (NICE) [NICE, 2007; NICE, 2011], and have been extrapolated to include the management of older children and adults.

Trigger factors

The following have been identified as trigger factors for flares of atopic eczema:

Dietary factors: a review article states that food allergens readily provoke atopic eczema in about 35% of people. Milk, egg, wheat, soy, and peanut account for 75% of the cases of food-induced atopic eczema [Greenhawt, 2010].

The possibility of a food allergy should be considered in people with atopic eczema [NICE, 2011].

Irritants [Beltrani and Boguneiwicz, 2003]:

Soaps, detergents, and chemicals reduce the already depleted lipid barrier on the skin or may act directly as an allergen.

Temperature: most people are aware of improvements in their eczema during the summer, with worsening symptoms in the winter. Sweating can provoke a flare or eczema at any time of year.

Fabrics [Mason, 2008]:

Synthetic fabrics and wool tend to itch and irritate the skin.

Cotton fabric is usually recommended; however, its structure contains short fibres which expand and contract, causing a rubbing movement that can irritate delicate skin. The dyes used in coloured cotton garments can increase the risk of a sensitivity reaction.

Silk fabric is often closely woven, thereby impeding the flow of air, and some people are allergic to the sericin protein in silk.

Inhaled allergens: those most commonly implicated include house-dust mites, pollens, pet dander, and moulds [Beltrani and Boguneiwicz, 2003]. Sensitization to inhaled allergens increases with age [NICE, 2007].

Hormonal triggers [Beltrani and Boguneiwicz, 2003]:

In a survey, 30% of women reported premenstrual flares of their atopic eczema, and pregnancy was noted to have an adverse effect on 52% of women with atopic eczema, during the first and second trimester (improvement was noted in the third trimester).

A prospective study of 200 pregnant women reported a very high prevalence of eczema.

NICE recommends that a diagnosis of [NICE, 2007]:

Food allergy should be considered in children with atopic eczema who have reacted previously to a food with immediate symptoms, or in infants and young children with moderate or severe atopic eczema that has not been controlled by optimum management, especially if associated with gut dysmotility (colic, vomiting, altered bowel habit) or failure to thrive [NICE, 2011].

Inhalant allergy should be considered in children with seasonal flares of atopic eczema, children with atopic eczema associated with asthma or allergic rhinitis, and children aged 3 years or over with atopic eczema on the face, especially around the eyes.

Allergic contact dermatitis should be considered in children with an exacerbation of previously controlled atopic eczema, or with reactions to topical treatments.

Allergy testing

The NICE Guideline Development Group could not find any trials examining the accuracy of tests for diagnosing inhalant allergies, nor tests investigating reactions to climatic, psychological, or environmental triggers in atopic eczema [NICE, 2007].

NICE recommends that if a food allergy is suspected, a healthcare professional with the appropriate competencies should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person. Management will depend on the results of this. For more information, see the NICE guideline Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community settings (pdf) [NICE, 2011].

CKS recommends that if the expertise and support are not available in primary care, referral to secondary care should be made.

Management

Management

Scenario: Mild eczema : covers the management of a person with areas of dry skin and/or infrequent itching (with or without small areas of redness).

Scenario: Moderate eczema : covers the management of a person with areas of dry skin, frequent itching, and redness (with or without excoriation and localized skin thickening).

Scenario: Severe eczema : covers the management of a person with widespread areas of dry skin, incessant itching, and redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation).

Scenario: Infected eczema : covers the additional management of infected eczema (indicated by areas of weeping, crusting, or pustules; fever or malaise; rapidly worsening eczema; or eczema that has failed to respond to treatment) with antibiotics and/or antiseptics.

Scenario: Mild eczema

Scenario: Mild eczema

1months3060monthsBoth

Information and self-care advice

What information and self-care advice should I give about eczema?

In children, reassure parents that eczema often improves with time.

In adults, explain that eczema is a chronic illness characterized by flares, but that these can usually be controlled with appropriate treatment.

Advise the person or carer:

To avoid scratching their eczema (if possible), and simply rub the area with their fingers to alleviate itch.

To keep nails short (and use anti-scratch mittens in babies with eczema).

To avoid trigger factors known to exacerbate eczema, such as clothing (they should avoid wearing synthetic fibres), soaps or detergents (use emollient substitutes), animals, and heat (keep rooms cool).

House-dust mite avoidance strategies are generally not recommended as they are time consuming and of limited benefit.

That complementary therapies are not generally recommended, and that a healthcare professional should be informed if these are used.

That they should not alter their diet unless under specialist advice.

Basis for recommendation

Basis for recommendation

These recommendations are based mainly on the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], and have been extrapolated to include the management of older children and adults.

Avoiding scratching: the benefit of the short-term relief by scratching the skin is counteracted by a simultaneous damage of the epidermis, leading to increased transepidermal water loss and drying, which in turn results in a cycle of more itching and more scratching [Buddenkotte et al, 2010].

House-dust mite avoidance: limited evidence suggests improvements in atopic eczema if very low levels of house-dust mite are achieved. The practicality of achieving such low levels in everyday life is uncertain. NICE does not recommend house-dust mite elimination [NICE, 2007].

Irritants, temperature, humidity, pet removal, and stress: NICE found no evidence regarding avoidance of such triggers. However, if these triggers exacerbate eczema, they should be avoided where possible.

Dietary modification:

Evidence from a Cochrane systematic review (search date: March 2006) suggests that there is no benefit from milk and egg-free exclusion diets in people who do not have a known allergy to specific foods [Bath-Hextall et al, 2008].

NICE recommends that if a food allergy is suspected, a healthcare professional with the appropriate competencies should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person. Management will depend on the results of this. For more information, see the NICE guideline Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community settings (pdf) [NICE, 2011].

There is limited evidence to recommend the use of few-food diets, elemental diets, probiotic supplements, sodium cromoglicate, dietary exclusion in breastfeeding women [NICE, 2007], or dietary supplementation with zinc, essential fatty acids, or vitamin B6 [Bath-Hextall and Williams, 2007] for the management of eczema.

Treatment of mild flares

How should I treat an acute flare of mild eczema?

Prescribe generous amounts of emollients and advise frequent and liberal use.

Consider prescribing a mild topical hydrocortisone cream or ointment (such as hydrocortisone 1%) for areas of red skin. Treatment should be continued for 48 hours after the flare has been controlled.

For more information on maximizing the benefit of emollients and topical corticosteroids, see the prescribing information sections on Emollients and Topical corticosteroids.

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], and have been extrapolated to include the management of older children and adults.

Definition of flare

There is no accepted or formal definition of what constitutes a flare of eczema [Langan et al, 2006]. NICE is pragmatic, and defines a flare of eczema as 'an increase in clinical severity (redness, oedema, or itching) of the condition' [National Collaborating Centre for Women's and Children's Health, 2007].

Treatments in primary care

NICE recommends a stepped approach for managing atopic eczema. This means that treatment should be tailored to the severity of the eczema, and stepped up or down according to the severity of symptoms [NICE, 2007].

NICE recommends that emollients should form the basis of management and should always be used, even when the skin is clear. However, despite unequivocal recommendations, there is limited evidence of effectiveness available from controlled trials.

Topical corticosteroids are recommended for areas of inflamed eczema. However, evidence from controlled trials for the effectiveness of topical corticosteroids is mainly limited to short-term studies, and there is a lack of relevant data on the optimal use of corticosteroids for the control of eczema [Hoare et al, 2000].

NICE recommends that the potency of the topical steroid should be tailored to the severity of the eczema, which may vary according to body site [NICE, 2007].

Controlling mild eczema

How should I maintain the skin in people prone to mild flares of eczema?

Advise the continued avoidance of trigger factors, where possible.

Encourage the frequent and liberal use of emollients, even during periods where the skin is clear.

Maintenance treatment with corticosteroids should not be necessary for mild eczema.

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guidelines Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007] and Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011]. Recommendations from the NICE guideline have been extrapolated to include the management of older children and adults.

Emollients are almost universally recommended as first-line treatment for atopic eczema [Hoare et al, 2000; NICE, 2007], and are essential for maintenance, even when the skin is clear [NICE, 2007]. However, despite unequivocal recommendations, there is limited evidence of effectiveness available from controlled trials.

NICE states that treating dry skin (an early sign of a flare) with an emollient may prevent the flare worsening. Scratching is thought to be a major component of flare progression, as it physically damages the skin, and can delay healing or facilitate infection. Emollients are believed to ease itching and thus may have a role in breaking the itch-scratch cycle [Grimalt et al, 2007].

Follow up for mild eczema

How should I follow up a person with mild eczema?

Mild eczema rarely requires active follow up unless the person or carer requests it.

For people with persisting eczema, consider annual review of emollient use to ensure optimal usage.

Basis for recommendation

Basis for recommendation

These recommendations are consistent with the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], although the specific recommendations for follow up are incomplete. Where this is the case, CKS offers guidance based on pragmatism and good clinical practice.

NICE states that the repeat prescribing of emollients over long periods without review should be discouraged, and annual reviews should be carried out [NICE, 2007]. However, this may not be necessary in people with small areas of mild eczema that requires minimal intervention.

Referral for mild eczema

When should I refer a person with mild eczema?

Refer for a routine dermatology appointment if:

The diagnosis is, or has become, uncertain.

Current management has not controlled eczema satisfactorily (for example the person is having one to two flares per month), or the person is reacting adversely to many emollients.

Facial eczema has not responded to appropriate treatment.

There is recurrent secondary infection.

Refer to a clinical psychologist, people whose eczema is controlled, but whose quality of life and psychological well-being have not improved (this may not be directly related to the severity of the eczema).

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guidelines Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007] and Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011]. Recommendations from the NICE guideline have been extrapolated to include the management of older children and adults.

The NICE Guideline Development Group (GDG) could not find any clinical evidence or evidence on cost-effectiveness in relation to referral and treatment outcomes for eczema, therefore, these recommendations are based on referral advice from other guidance [Primary Care Dermatology Society and BAD, 2010], and the GDG's collective experience.

Referral for allergy testing is rarely necessary as mild eczema is by definition well controlled, and people with mild eczema are less likely to have significant allergies [NICE, 2007].

Treatments not recommended

What treatments are not generally recommended?

Complementary therapies are not generally recommended for the treatment of atopic eczema. Advise that:

Treatments such as homeopathy, herbal medicine, massage, and food supplements (such as evening primrose oil) have not been adequately assessed in clinical trials.

All therapies that claim effectiveness (including natural remedies) may also have adverse effects.

Chinese herbal medicines have been associated with life-threatening adverse effects, and have in some cases been contaminated with corticosteroids.

If a person insists on using complementary therapies, advise on the continued use of emollients (frequently and liberally, even when the skin is clear).

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], and have been extrapolated to include the management of older children and adults.

The evidence to support complementary therapies is limited, and the available randomized controlled trials are generally of poor quality. NICE states that 'there is insufficient evidence for complementary therapies (homeopathy, herbal medicine, massage, and food supplements) to make recommendations for their use in clinical practice' [NICE, 2007].

The Medicines and Healthcare products Regulatory Agency (MHRA) warns that the phrases 'natural', 'herbal', and 'derived from plants' do not necessarily mean that the product is 'safe'. Herbal medicines, like other medicines, can have adverse effects. They can also interact with other medicines, resulting in reduced or enhanced effects of the other medicines. For further information, see www.mhra.gov.uk/safetyinformation [MHRA, 2012].

A study was conducted at the paediatric dermatology clinic in Birmingham Children’s Hospital to determine whether herbal creams reported as being effective for the treatment of childhood atopic eczema contained corticosteroids. The parents of children who reported using herbal creams with good effect for atopic eczema (n = 19) were asked to submit the cream for analysis. Twenty four creams were analyzed [Ramsay et al, 2003]:

Five creams labelled Wau Wa contained clobetasol propionate. Further analysis suggested that it also contained about 20% proprietary Dermovate® cream in a paraffin base.

Two labelled Muijiza cream contained clobetasol propionate.

Thirteen of 17 unnamed creams contained corticosteroids: clobetasol proprionate (n = 4), clobetasol proprionate plus hydrocortisone (n = 1), betamethasone valerate (n = 2), clobetasone butyrate (n = 3), and hydrocortisone (n = 2); there was an unidentified peak in one cream.

All parents believed the creams were herbal, free from steroids, and safe for use on their children. Many of the creams cost over £25 and their use was often only reported when the parent could no longer afford to continue the treatment, resulting in worsening of their child’s eczema.

The authors concluded that there is an urgent need for tighter regulation of herbal creams and for increased public education about the potential dangers of alternative therapies.

Scenario: Moderate eczema

Scenario: Moderate eczema

1months3060monthsBoth

Information and self-care advice

What information and self-care advice should I give about eczema?

In children, reassure parents that eczema often improves with time.

In adults, explain that eczema is a chronic illness characterized by flares, but that these can usually be controlled with appropriate treatment.

Advise the person or carer:

To avoid scratching their eczema (if possible), and simply rub the area with their fingers to alleviate itch.

To keep the nails short (and use anti-scratch mittens in babies with eczema).

To avoid trigger factors known to exacerbate eczema such as clothing (they should avoid wearing synthetic fibres), soaps or detergents (use emollient substitutes), animals, and heat (keep rooms cool).

House-dust mite avoidance strategies are generally not recommended as they are time consuming and of limited benefit.

That complementary therapies are not generally recommended, and that a healthcare professional should be informed if these are used.

That they should not alter their diet unless under specialist advice. Breastfeeding mothers of children with atopic eczema should not alter their diets unless under specialist advice (see Advice for breastfed and bottle fed infants for more information).

Basis for recommendation

Basis for recommendation

These recommendations are based mainly on the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], and have been extrapolated to include the management of older children and adults.

Avoiding scratching: the benefit of the short-term relief by scratching the skin is counteracted by a simultaneous damage of the epidermis, leading to increased transepidermal water loss and drying, which in turn results in a cycle of more itching and more scratching [Buddenkotte et al, 2010].

House-dust mite avoidance: limited evidence suggests improvements in atopic eczema if very low levels of house-dust mite are achieved. The practicality of achieving such low levels in everyday life is uncertain. NICE does not recommend house-dust mite elimination [NICE, 2007].

Irritants, temperature, humidity, pet removal, and stress: NICE found no evidence regarding avoidance of such triggers. However, if these triggers exacerbate eczema, they should be avoided where possible.

Dietary modification:

Evidence from a Cochrane systematic review (search date: March 2006) suggests that there is no benefit from milk and egg-free exclusion diets in people who do not have a known allergy to specific foods [Bath-Hextall et al, 2008].

NICE recommends that if a food allergy is suspected, a healthcare professional with the appropriate competencies should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person. Management will depend on the results of this. For more information, see the NICE guideline Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community settings (pdf) [NICE, 2011].

There is limited evidence to recommend the use of few-food diets, elemental diets, probiotic supplements, sodium cromoglicate, dietary exclusion in breastfeeding women [NICE, 2007], or dietary supplementation with zinc, essential fatty acids, or vitamin B6 [Bath-Hextall and Williams, 2007] for the management of eczema.

Treatment of moderate flares

How should I treat acute flares of moderate eczema?

Consider the possibility of trigger factors or infection, which can precipitate or worsen a flare.

Prescribe intensive treatment until the flare is controlled (this may involve more potent treatment than usual).

Prescribe a generous amount of emollients and advise frequent and liberal use (more than usual).

Prescribe a moderately potent topical corticosteroid to be used on inflamed areas (for example betamethasone valerate 0.025% or clobetasone butyrate 0.05%). Treatment should be continued for 48 hours after the flare has been controlled.

For delicate areas of skin such as the face and flexures, consider starting with a mild potency topical corticosteroid (such as hydrocortisone 1%) and increase to a moderate potency corticosteroid only if necessary. Aim for a maximum of 5 days use.

Occlusive dressings or dry bandages may be of benefit; however, treatment should only be started by a healthcare professional trained in their use (otherwise consider referral).

If there are areas of infected skin, treat with a topical antibiotic. See Scenario: Infected eczema.

For more information on maximizing the benefit of emollients and topical corticosteroids, see the prescribing information sections on Emollients and Topical corticosteroids.

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guidelines Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007] and Management of atopic eczema in primary care issued by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011]. Recommendations from the NICE guideline have been extrapolated to include the management of older children and adults.

Definition of flare

There is no accepted or formal definition of what constitutes a flare of eczema [Langan et al, 2006]. NICE is pragmatic, and defines a flare of eczema as 'an increase in clinical severity (redness, oedema, or itching) of the condition' [NICE, 2007].

Treatments available in primary care

NICE recommends a stepped approach for managing atopic eczema. This means that treatment should be tailored to the severity of the eczema, and stepped up or down according to the severity of symptoms [NICE, 2007].

NICE recommends that emollients should form the basis of management and should always be used, even when the skin is clear. However, despite unequivocal recommendations, there is limited evidence of effectiveness available from controlled trials.

Topical corticosteroids are recommended for areas of inflamed eczema. However, evidence from controlled trials for the effectiveness of topical corticosteroids is mainly limited to short-term studies, and there is a lack of relevant data on the optimal use of corticosteroids for the control of eczema [Hoare et al, 2000].

NICE recommends that the potency of the topical steroid should be tailored to the severity of the eczema, which may vary according to body site [NICE, 2007].

The recommendation to consider a mild potency topical corticosteroid for use on the face and flexures is based on advice from the guideline Management of atopic eczema in primary care issued by SIGN [SIGN, 2011].

Controlling moderate eczema

How should I maintain the skin in people prone to moderate flares of eczema?

Advise the continued avoidance of trigger factors where possible, and give advice on preventing infection.

Prescribe preventative treatment according to the usual severity of the condition between flares:

Encourage the frequent and liberal use of emollients during periods where the eczema appears controlled, even if the skin is clear.

Consider prescribing topical corticosteroids to control areas of skin prone to frequent flares (not recommended for the face, genitals, or axillae). Consider one of the following maintenance regimens:

A step down approach: prescribe the lowest potency and amount of topical corticosteroid necessary to control the condition (for example prescribe a mild corticosteroid such as hydrocortisone 1%).

Intermittent treatment: advise the use of topical corticosteroids on two consecutive days, once a week (weekend therapy); or the use of topical corticosteroids twice a week, for example every 3–4 days (twice weekly therapy).

See Regimen for maintenance for more information on maintenance treatment for chronic eczema.

Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are a second-line option. However, they should only be prescribed by a specialist (including GPs with a specialist interest in dermatology).

If there is severe itch of urticaria, consider prescribing a one-month trial of a non-sedating antihistamine (such as cetirizine).

Provide information on recognizing the early or prodromal signs and symptoms of a flare. Should this occur, advise immediate and aggressive treatment using an agreed stepped-care plan.

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guidelines Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007] and Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011]. Recommendations from the NICE guideline have been extrapolated to include the management of older children and adults.

Treatments available in primary care

NICE recommends a stepped approach for managing atopic eczema. This means that treatment should be tailored to the severity of the eczema, and stepped up or down according to the severity of symptoms [NICE, 2007].

NICE recommends that emollients should form the basis of management and should always be used, even when the skin is clear. However, despite unequivocal recommendations, there is limited evidence of effectiveness available from controlled trials.

Topical corticosteroids are recommended for areas of inflamed eczema. However, evidence from controlled trials for the effectiveness of topical corticosteroids is mainly limited to short-term studies, and there is a lack of relevant data on the optimal use of corticosteroids for the control of eczema [Hoare et al, 2000].

NICE recommends that the potency of the topical steroid should be tailored to the severity of the eczema, which may vary according to body site [NICE, 2007].

Although the use of corticosteroids should be limited between flares (in an ideal scenario only emollients should be used between flares), CKS recognizes that some people will require long-term management with a corticosteroid to control their condition.

The step down approach is not specifically recommended by NICE for the control of flares, but is implied in their clinical guideline. This requires the person to use the lowest amount and potency of corticosteroid to control eczema, in an attempt to minimize adverse effects (for more information, see Regimen for maintenance).

Intermittent treatment

The weekend therapy is recommended by NICE and may prevent flares occurring. There is good evidence from four randomized controlled trials (RCTs) that intermittent treatment with a topical corticosteroid (on 2 or 3 consecutive days) can reduce flare recurrence.

The twice weekly therapy is recommended by SIGN, who advises that although constant use of topical corticosteroids is undesirable due to the risk of local and systemic adverse effects, twice weekly maintenance treatment with a topical corticosteroid should be considered in people with moderate to severe atopic eczema experiencing frequent relapses [SIGN, 2011].

For more information, see Regimen for maintenance.

Non-sedating antihistamines are not recommended for routine use by NICE, but may be an option for the treatment of mild or moderate atopic eczema where there is severe itching or urticaria. This recommendation is based mainly on clinical experience, as there is only very limited evidence from controlled trials on the effectiveness of antihistamines for the treatment of atopic eczema.

Histamine has been suggested to play a major role in the pathogenesis of atopic eczema, and antihistamines are prescribed to the vast majority of people with atopic eczema suffering from itch [Buddenkotte et al, 2010].

Tacrolimus and pimecrolimus (topical calcineurin inhibitors) have been shown to be effective in the treatment of atopic eczema [Iskedjian et al, 2004; Ashcroft et al, 2007]. Following a Technology Appraisal on their use for atopic eczema, NICE states that tacrolimus and pimecrolimus [NICE, 2004a]:

Are not recommended as first-line treatments for atopic eczema of any severity.

Tacrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate to severe atopic eczema in adults and children aged 2 years and older that has not been controlled by topical corticosteroids, where there is a serious risk of important adverse effects from further topical corticosteroid use, especially irreversible skin atrophy.

Pimecrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate atopic eczema on the face and neck in children aged 2 to 16 years that has not been controlled by topical corticosteroids, where there is a serious risk of important adverse effects from further topical corticosteroid use, especially irreversible skin atrophy.

Should be initiated 'only by physicians (including general practitioners) with a special interest and experience in dermatology, and only after careful discussion with the person about the potential risks and benefits of all appropriate second-line treatment options'.

Early identification of flares

Identifying a flare early is considered to be important, as early treatment can reduce the severity of the flare and allow for more conservative treatment measures (such as emollients alone and reduced use of topical corticosteroids).

The NICE guideline development group states that treating dry skin (an early sign of a flare) with an emollient may prevent the flare worsening. Scratching is thought to be a major component of flare progression, as it physically damages the skin, and can delay healing or facilitate infection [NICE, 2007]. Emollients are believed to ease itching and thus may have a role in breaking the itch-scratch cycle [Grimalt et al, 2007].

Early application of topical corticosteroids may prevent the flare from worsening, and thus lead to reduced use of corticosteroids in the longer term [NICE, 2007].

Follow up for moderate eczema

How should I follow up a person with moderate eczema?

Optimal follow up depends on a number of factors such as the severity of the condition, the treatment the person is receiving, and their health and age (for instance, more frequent follow up will be needed in a small child receiving large amounts of moderately potent topical corticosteroids).

Review emollient use on an annual basis to ensure optimal usage.

Topical corticosteroids require regular review if there is heavy usage; however, this is unlikely to be necessary with moderate eczema. Review maintenance therapy with topical corticosteroids (that is, step-down or intermittent treatment) at 3–6 months to assess effectiveness.

Review the use of non-sedating antihistamines every 3 months (the drug can be stopped, then restarted if symptoms worsen).

Basis for recommendation

Basis for recommendation

These recommendations are consistent with the clinical guidelines Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007] and Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011]. However, the specific recommendations for follow up in these guidelines are incomplete. Where this is the case, CKS offers guidance based on pragmatism and good clinical practice.

A follow-up appointment is a good opportunity to reinforce the continued need to practise good skin care, in particular, to encourage the frequent and liberal use of emollients. The NICE Guideline Development Group states that the repeat prescribing of emollients over long periods without review should be discouraged, and annual reviews should be carried out [NICE, 2007].

Evidence from controlled studies on the long-term safety of topical corticosteroids is limited, and there is no recommendation from NICE on the optimal time for review of people using topical corticosteroids, although it is recommended that people should be referred if they are not responding adequately to treatment with topical corticosteroids [NICE, 2007].

NICE states that the weekend therapy (that is, the use of topical corticosteroids for two consecutive days to prevent flares) should be reviewed within 3 to 6 months to assess effectiveness [NICE, 2007]. CKS has extrapolated this recommendation to the step down and the twice weekly regimens.

Referral for moderate eczema

When should I refer a person with moderate eczema?

Admit to hospital if eczema herpeticum (widespread herpes simplex virus) is suspected.

Refer for a routine dermatology appointment if:

The diagnosis is, or has become, uncertain.

Current management has not controlled eczema satisfactorily (for example the person is having one to two flares per month), or the person is reacting adversely to many emollients.

Facial eczema has not responded to appropriate treatment.

Treatment (application) advice is needed (for example bandaging techniques).

Contact allergic dermatitis is suspected (for example if there is persistent eczema or facial, eyelid, or hand eczema).

There is recurrent secondary infection.

Eczema is associated with significant social or psychological problems (for example sleep disturbance).

Refer people in whom a food allergy is suspected (to immunology, dermatology, or paediatrics) if the expertise to diagnose and manage food allergy is not available in primary care.

Refer to a clinical psychologist, people whose eczema is controlled, but whose quality of life and psychological well-being have not improved (this may not be directly related to the severity of the eczema).

Advice for breastfed and bottle fed infants

Breastfed and bottle fed infants

The mothers of breastfed infants in whom allergy is suspected to be the cause of moderate or severe eczema may require referral for dietary advice. An allergen-specific exclusion diet may be considered; if this is not possible, the infant may be switched to a specialist formula milk (for example hypoallergenic hydrolyzed or amino acid-based products).

A 6–8 week trial of hydrolyzed protein formula milk or amino acid formula milk may be tried in bottle-fed children less than 6 months of age with eczema that is not controlled by emollients and mild topical corticosteroids.

Children who respond well to a change in their milk formula will require referral to a dietitian for further dietary advice to ensure healthy growth and development.

Children who do not respond are less likely to have a cow's milk allergy and should restart cow's milk, with monitoring of their eczema.

Goat's milk and sheep's milk should not be used as they are nutritionally inadequate for human growth. Goat's milk, in any case, shares 95% of cross-reacting allergens with cow's milk.

Partially hydrolyzed formula milks are not suitable as the incomplete hydrolyzation process may be inadequate to completely eliminate all allergens.

Soya protein diets can be used in children 6 months of age and older, following specialist advice. Such diets require careful balancing of nutritional content, and children who consume a soya based diet may be more likely to develop a peanut allergy.

Advice should be sought from a dietitian with appropriate competencies.

[NICE, 2007; NICE, 2011]

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guidelines Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007] and Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011]. Recommendations from the NICE guideline have been extrapolated to include the management of older children and adults.

The NICE Guideline Development Group (GDG) could not find any clinical evidence or evidence on cost-effectiveness in relation to referral and treatment outcomes for eczema. Therefore, these recommendations are based on referral advice from other guidance [Primary Care Dermatology Society and BAD, 2010], and the GDG's collective experience.

These recommendations are designed to reflect current clinical practice, ensuring that people who require a referral are referred more promptly and that inappropriate referrals are minimized.

NICE recommends that if a food allergy is suspected, a healthcare professional with the appropriate competencies should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person. Management will depend on the results of this. For more information, see the NICE guideline Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community settings (pdf) [NICE, 2011].

CKS recommends that if the expertise and support are not available in primary care, referral to secondary care should be made.

Eczema herpeticum is potentially life-threatening and if suspected should prompt emergency admission for confirmation of the diagnosis and antiviral treatment [NICE, 2007].

Treatments not recommended

What treatments are not recommended?

Complementary therapies are not generally recommended for the treatment of atopic eczema. Advise that:

Treatments such as homeopathy, herbal medicine, massage, and food supplements (such as evening primrose oil) have not been adequately assessed in clinical trials.

All therapies that claim effectiveness may also have adverse effects, including natural remedies.

Chinese herbal medicines have been associated with life-threatening adverse effects, and have in some cases been contaminated with corticosteroids.

If a person insists on using complementary therapies, advise on the continued use of emollients (frequently and liberally, even when the skin is clear).

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], and have been extrapolated to include the management of older children and adults.

The evidence to support complementary therapies is limited, and the available randomized controlled trials are generally of poor quality. NICE states that 'there is insufficient evidence for complementary therapies (homeopathy, herbal medicine, massage, and food supplements) to make recommendations for their use in clinical practice' [NICE, 2007].

The Medicines and Healthcare products Regulatory Agency (MHRA) warns that the phrases 'natural', 'herbal', and 'derived from plants' do not necessarily mean that the product is 'safe'. Herbal medicines, like other medicines, can have adverse effects. They can also interact with other medicines, resulting in reduced or enhanced effects of the other medicines. For further information, see www.mhra.gov.uk/safetyinformation [MHRA, 2012].

A study was conducted at the paediatric dermatology clinic in Birmingham Children’s Hospital to determine whether herbal creams reported as being effective for the treatment of childhood atopic eczema contained corticosteroids. The parents of children who reported using herbal creams with good effect for atopic eczema (n = 19) were asked to submit the cream for analysis. Twenty four creams were analyzed [Ramsay et al, 2003]:

Five creams labelled Wau Wa contained clobetasol propionate. Further analysis suggested that it also contained about 20% proprietary Dermovate® cream in a paraffin base.

Two labelled Muijiza cream contained clobetasol propionate.

Thirteen of 17 unnamed creams contained corticosteroids: clobetasol proprionate (n = 4), clobetasol proprionate plus hydrocortisone (n = 1), betamethasone valerate (n = 2), clobetasone butyrate (n = 3), and hydrocortisone (n = 2); there was an unidentified peak in one cream.

All parents believed the creams were herbal, free from steroids, and safe for use on their children. Many of the creams cost over £25 and their use was often only reported when the parent could no longer afford to continue the treatment, resulting in worsening of their child’s eczema.

The authors concluded that there is an urgent need for tighter regulation of herbal creams and for increased public education about the potential dangers of alternative therapies.

Scenario: Severe eczema

Scenario: Severe eczema

1months3060monthsBoth

Information and self-care advice

What information and self-care advice should I give about eczema?

In children, reassure parents that eczema often improves with time.

In adults, explain that eczema is a chronic illness characterized by flares, but that these can usually be controlled with appropriate treatment.

Advise the person or carer:

To avoid scratching their eczema (if possible), and simply rub the area with their fingers to alleviate itch.

To keep the nails short (and use anti-scratch mittens in babies with eczema).

To avoid trigger factors known to exacerbate eczema such as clothing (they should avoid wearing synthetic fibres), soaps or detergents (use emollient substitutes), animals, and heat (keep rooms cool).

House-dust mite avoidance strategies are generally not recommended as they are time consuming and of limited benefit.

That complementary therapies are not generally recommended, and that a healthcare professional should be informed if these are used.

That they should not alter their diet unless under specialist advice. Advise breastfeeding mothers of children with atopic eczema that they should not alter their diets unless under specialist advice (see Advice for breastfed and bottle fed infants for more information).

Basis for recommendation

Basis for recommendation

These recommendations are based mainly on the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], and have been extrapolated to include the management of older children and adults.

Avoiding scratching: the benefit of the short-term relief by scratching the skin is counteracted by a simultaneous damage of the epidermis, leading to increased transepidermal water loss and drying, which in turn results in a cycle of more itching and more scratching [Buddenkotte et al, 2010].

House-dust mite avoidance: limited evidence suggests improvements in atopic eczema if very low levels of house-dust mite are achieved. The practicality of achieving such low levels in everyday life is uncertain. NICE does not recommend house-dust mite elimination [NICE, 2007].

Irritants, temperature, humidity, pet removal, and stress: NICE found no evidence regarding avoidance of such triggers. However, if these triggers exacerbate eczema, they should be avoided where possible.

Dietary modification:

Evidence from a Cochrane systematic review (search date: March 2006) suggests that there is no benefit from milk and egg-free exclusion diets in people who do not have a known allergy to specific foods [Bath-Hextall et al, 2008].

NICE recommends that if a food allergy is suspected, a healthcare professional with the appropriate competencies should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person. Management will depend on the results of this. For more information, see the NICE guideline Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community settings (pdf) [NICE, 2011].

There is limited evidence to recommend the use of few-food diets, elemental diets, probiotic supplements, sodium cromoglicate, dietary exclusion in breastfeeding women [NICE, 2007], or dietary supplementation with zinc, essential fatty acids, or vitamin B6 [Bath-Hextall and Williams, 2007] for the management of eczema.

Treatment of severe flares

How should I treat an acute flare of severe eczema?

Consider the possibility of trigger factors or infection, which can precipitate or worsen a flare.

Prescribe intensive treatment until the flare is controlled (this may involve more potent treatment than usual).

Prescribe a generous amount of emollients and advise frequent and liberal use (more than usual).

Prescribe a potent topical corticosteroid for inflamed areas (for example betamethasone valerate 0.1%).

For delicate areas of skin such as the face and flexures, use a moderate potency corticosteroid (such as betamethasone valerate 0.025%, clobetasone butyrate 0.05%). Aim for a maximum of 5 days use.

If itching is severe and affecting sleep, consider prescribing a sedating antihistamine (such as chlorphenamine) for adults and children aged 6 months or over (maximum two-week course).

Occlusive dressings or dry bandages may be of benefit; however, treatment should only be started by a healthcare professional trained in their use (otherwise consider referral).

If there is severe, extensive eczema causing psychological distress, consider prescribing a short course of oral corticosteroids (refer children under 16 years). There are no data from controlled trials, but 30 mg prednisolone taken in the morning for 1 week should be sufficient.

If there are signs of infection, consider prescribing an oral antibiotic. Areas of infected skin may require treatment with a topical antibiotic. See Scenario: Infected eczema.

For more information on the treatment of severe eczema, see the prescribing information sections on Emollients, Topical corticosteroids, Antihistamines, and Oral corticosteroids.

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guidelines Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007] and Management of atopic eczema in primary care issued by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011]. Recommendations from the NICE guideline have been extrapolated to include the management of older children and adults.

Definition of flare

There is no accepted or formal definition of what constitutes a flare of eczema [Langan et al, 2006]. NICE is pragmatic, and defines a flare of eczema as 'an increase in clinical severity (redness, oedema, or itching) of the condition' [NICE, 2007].

Treatments available in primary care

NICE recommends a stepped approach for managing atopic eczema. This means that treatment should be tailored to the severity of the eczema, and stepped up or down according to the severity of symptoms [NICE, 2007].

NICE recommends that emollients should form the basis of management and should always be used, even when the skin is clear. However, despite unequivocal recommendations, there is limited evidence of effectiveness available from controlled trials.

Topical corticosteroids are recommended for areas of inflamed eczema. However, evidence from controlled trials for the effectiveness of topical corticosteroids is mainly limited to short-term studies, and there is a lack of relevant data on the optimal use of corticosteroids for the control of eczema [Hoare et al, 2000].

NICE recommends that the potency of the topical steroid should be tailored to the severity of the eczema, which may vary according to body site [NICE, 2007].

The recommendation to use a moderate potency topical corticosteroid for use on the face and flexures is based on advice from the guideline Management of atopic eczema in primary care issued by SIGN [SIGN, 2011].

Sedating antihistamines promote sleep and may help break the itch-scratch cycle during severe flares. They are recommended on the basis of clinical experience, as evidence from controlled trials is extremely limited.

Sedating antihistamines at night can be useful for helping to break the itch-scratch cycle, but should not be used on a long-term basis [Baron et al, 2012].

Histamine has been suggested to play a major role in the pathogenesis of atopic eczema, and antihistamines are prescribed to the vast majority of people with atopic eczema suffering from itch [Buddenkotte et al, 2010].

Oral corticosteroids (prednisolone) should be reserved for use in the treatment of severe flares, often while waiting for referral to secondary care where the condition can be fully assessed and other treatment options can be tried. There is no evidence from controlled trials to support the effectiveness of oral corticosteroids, but clinical experience suggests that there is a large and rapid treatment effect. Prolonged or frequent treatment should be avoided as there is a cumulative risk of serious adverse effects.

The suggested dose is based on expert opinion in a review article [Charman and Williams, 2003].

Controlling severe eczema

How should I maintain the skin in people prone to severe flares of eczema?

Advise the continued avoidance of trigger factors where possible, and give advice on preventing infection.

Prescribe preventative treatment according to the usual severity of the condition between flares:

Encourage the frequent and liberal use of emollients during periods where the eczema appears controlled, even if the skin is clear.

Consider prescribing topical corticosteroids to control areas of skin prone to frequent flares (not recommended for the face, genitals, or axillae). Consider one of the following maintenance regimens:

A step down approach: prescribe the lowest potency and amount of topical corticosteroid necessary to control the condition (for example prescribe a mild corticosteroid such as hydrocortisone 1%).

Intermittent treatment: advise the use of topical corticosteroids on two consecutive days, once a week (weekend therapy); or the use of topical corticosteroids twice a week, for example every 3–4 days (twice weekly therapy).

See Regimen for maintenance for more information on maintenance treatment for chronic eczema.

Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are a second-line option. However, they should only be prescribed by a specialist (including GPs with a specialist interest in dermatology).

If there is severe itch of urticaria, consider prescribing a one-month trial of a non-sedating antihistamine (such as cetirizine).

Provide information on recognizing the early or prodromal signs and symptoms of a flare. Should this occur, advise immediate and aggressive treatment using an agreed stepped-care plan.

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guidelines Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007] and Management of atopic eczema in primary care issued by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011]. Recommendations from the NICE guideline have been extrapolated to include the management of older children and adults.

Treatments available in primary care

NICE recommends a stepped approach for managing atopic eczema. This means that treatment should be tailored to the severity of the eczema, and stepped up or down according to the severity of symptoms [NICE, 2007].

NICE recommends that emollients should form the basis of management and should always be used, even when the skin is clear. However, despite unequivocal recommendations, there is limited evidence of effectiveness available from controlled trials.

Topical corticosteroids are recommended for areas of inflamed eczema. However, evidence from controlled trials for the effectiveness of topical corticosteroids is mainly limited to short-term studies, and there is a lack of relevant data on the optimal use of corticosteroids for the control of eczema [Hoare et al, 2000].

NICE recommends that the potency of the topical steroid should be tailored to the severity of the eczema, which may vary according to body site [NICE, 2007].

Although the use of corticosteroids should be limited between flares (in an ideal scenario only emollients should be used between flares), CKS recognizes that some people will require long-term management with a corticosteroid to control their condition.

The step down approach is not specifically recommended by NICE for the control of flares, but is implied in their clinical guideline. This requires the person to use the lowest amount and potency of corticosteroid to control eczema, in an attempt to minimize adverse effects (for more information, see Regimen for maintenance).

Intermittent treatment

The weekend therapy is recommended by NICE and may prevent flares occurring. There is good evidence from four randomized controlled trials (RCTs) that intermittent treatment with a topical corticosteroid (on 2 or 3 consecutive days) can reduce flare recurrence.

The twice weekly therapy is recommended by SIGN, who advises that although constant use of topical corticosteroids is undesirable due to the risk of local and systemic adverse effects, twice weekly maintenance treatment with a topical corticosteroid should be considered in people with moderate to severe atopic eczema experiencing frequent relapses [SIGN, 2011].

For more information, see Regimen for maintenance.

Non-sedating antihistamines are not recommended for routine use by NICE, but may be an option for the treatment of mild or moderate atopic eczema where there is severe itching or urticaria. This recommendation is based mainly on clinical experience, as there is only very limited evidence from controlled trials on the effectiveness of antihistamines for the treatment of atopic eczema.

Histamine has been suggested to play a major role in the pathogenesis of atopic eczema, and antihistamines are prescribed to the vast majority of people with atopic eczema suffering from itch [Buddenkotte et al, 2010].

Tacrolimus and pimecrolimus (topical calcineurin inhibitors) have been shown to be effective in the treatment of atopic eczema [Iskedjian et al, 2004; Ashcroft et al, 2007]. Following a Technology Appraisal on their use for atopic eczema, NICE states that tacrolimus and pimecrolimus [NICE, 2004a]:

Are not recommended as first-line treatments for atopic eczema of any severity.

Tacrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate to severe atopic eczema in adults and children aged 2 years and older that has not been controlled by topical corticosteroids, where there is a serious risk of important adverse effects from further topical corticosteroid use, especially irreversible skin atrophy.

Pimecrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate atopic eczema on the face and neck in children aged 2 to 16 years that has not been controlled by topical corticosteroids, where there is a serious risk of important adverse effects from further topical corticosteroid use, especially irreversible skin atrophy.

Should be initiated 'only by physicians (including general practitioners) with a special interest and experience in dermatology, and only after careful discussion with the person about the potential risks and benefits of all appropriate second-line treatment options'.

Early identification of flares

Identifying a flare early is considered to be important, as early treatment can reduce the severity of the flare and allow for more conservative treatment measures (such as emollients alone and reduced use of topical corticosteroids).

The NICE guideline development group states that treating dry skin (an early sign of a flare) with an emollient may prevent the flare worsening. Scratching is thought to be a major component of flare progression, as it physically damages the skin, and can delay healing or facilitate infection [NICE, 2007]. Emollients are believed to ease itching and thus may have a role in breaking the itch-scratch cycle [Grimalt et al, 2007].

Early application of topical corticosteroids may prevent the flare from worsening, and thus lead to reduced use of corticosteroids in the longer term [NICE, 2007].

Follow up for severe eczema

How should I follow up a person with severe eczema?

Optimal follow up depends on a number of factors, such as the severity of the illness, the treatment the person is receiving, and their health and age (for instance, more frequent follow up may be advisable in a small child receiving potent topical corticosteroids).

Review emollient use on an annual basis to ensure optimal usage.

Topical corticosteroids require regular review if there is heavy usage. Review maintenance therapy with topical corticosteroids (that is, step-down or intermittent treatment) at 3–6 months to assess effectiveness.

Review the use of non-sedating antihistamines every 3 months (the drug can be stopped, then restarted if symptoms worsen).

For all people who have had a severe and extensive flare requiring treatment with oral corticosteroids or oral antibiotics, review after the course has finished, and consider the need for referral.

Basis for recommendation

Basis for recommendation

These recommendations are consistent with the clinical guidelines Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007] and Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011]. However, the specific recommendations for follow up in these guidelines are incomplete. Where this is the case, CKS offers guidance based on pragmatism and good clinical practice.

A follow-up appointment is a good opportunity to reinforce the continued need to practise good skin care, in particular, to encourage the frequent and liberal use of emollients. The NICE Guideline Development Group states that the repeat prescribing of emollients over long periods without review should be discouraged, and annual reviews should be carried out [NICE, 2007].

Evidence from controlled studies on the long-term safety of topical corticosteroids is limited, and there is no recommendation from NICE on the optimal time for review of people using topical corticosteroids, although it is recommended that people should be referred if they are not responding adequately to treatment with topical corticosteroids [NICE, 2007].

NICE states that the weekend therapy (that is, the use of topical corticosteroids for two consecutive days to prevent flares) should be reviewed within 3 to 6 months to assess effectiveness [NICE, 2007]. CKS has extrapolated this recommendation to the step down and the twice weekly regimens.

People who have received systemic treatment for eczema or infection require a review to ensure treatment has been successful (if not, referral is required) [NICE, 2007].

Referral for severe eczema

When should I refer a person with severe eczema?

Admit to hospital if eczema herpeticum (widespread herpes simplex virus) is suspected.

Refer for a routine dermatology appointment if:

The diagnosis is, or has become, uncertain.

Current management has not controlled eczema satisfactorily (for example the person is having one to two flares per month), or the person is reacting adversely to many emollients.

Facial eczema has not responded to appropriate treatment.

Treatment (application) advice is needed (for example bandaging techniques).

Contact allergic dermatitis is suspected (for example there is persistent eczema or facial, eyelid, or hand eczema).

Eczema is associated with significant social or psychological problems (for example sleep disturbance).

There is recurrent secondary infection.

Refer people in whom a food allergy is suspected (to immunology, dermatology, or paediatrics) if the expertise to diagnose and manage food allergy is not available in primary care.

Refer to a clinical psychologist, people whose eczema is controlled, but whose quality of life and psychological well-being have not improved (this may not be directly related to the severity of the eczema).

Advice for breastfed and bottle fed infants

Breastfed and bottle fed infants

The mothers of breastfed infants in whom allergy is suspected to be the cause of moderate or severe eczema may require referral for dietary advice. If the expertise and support are available, an allergen-specific exclusion diet may be considered; if this is not possible, the infant may be switched to a specialist formula milk (for example hypoallergenic hydrolyzed or amino acid-based products).

A 6–8 week trial of hydrolyzed protein formula milk or amino acid formula milk may be tried in bottle-fed children less than 6 months of age with eczema that is not controlled by emollients and mild topical corticosteroids.

Children who respond well to a change in their milk formula will require referral to a dietitian for further dietary advice to ensure healthy growth and development.

Children who do not respond are less likely to have a cow's milk allergy and should restart cow's milk, with monitoring of their eczema.

Goat's milk and sheep's milk should not be used as they are nutritionally inadequate for human growth. Goat's milk, in any case, shares 95% of cross-reacting allergens with cow's milk.

Partially hydrolyzed formula milks are not suitable as the incomplete hydrolyzation process may be inadequate to completely eliminate all allergens.

Soya protein diets can be used in children 6 months of age and older, following specialist advice. Such diets require careful balancing of nutritional content, and children who consume a soya based diet may be more likely to develop a peanut allergy.

Advice should be sought from a dietitian with appropriate competencies.

[NICE, 2007; NICE, 2011]

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guidelines Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007] and Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011]. Recommendations from the NICE guideline have been extrapolated to include the management of older children and adults.

The NICE Guideline Development Group (GDG) could not find any clinical evidence or evidence on cost-effectiveness in relation to referral and treatment outcomes for eczema. Therefore, these recommendations are based on referral advice from other guidance [Primary Care Dermatology Society and BAD, 2010], and the GDG's collective experience.

These recommendations are designed to reflect current clinical practice, ensuring that people who require a referral are referred more promptly and that inappropriate referrals are minimized.

NICE recommends that if a food allergy is suspected, a healthcare professional with the appropriate competencies should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person. Management will depend on the results of this. For more information, see the NICE guideline Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community settings (pdf) [NICE, 2011].

CKS recommends that if the expertise and support are not available in primary care, referral to secondary care should be made.

Eczema herpeticum is potentially life-threatening and if suspected should prompt emergency admission for confirmation of the diagnosis and antiviral treatment [NICE, 2007].

Treatments not recommended

What treatments are not recommended?

Complementary therapies are not generally recommended for the treatment of atopic eczema. Advise that:

Treatments such as homeopathy, herbal medicine, massage, and food supplements (such as evening primrose oil) have not been adequately assessed in clinical trials.

All therapies that claim effectiveness may also have adverse effects, including natural remedies.

Chinese herbal medicines have been associated with life-threatening adverse effects, and have in some cases been contaminated with corticosteroids.

If a person insists on using complementary therapies, advise on the continued use of emollients (frequently and liberally, even when the skin is clear).

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], and have been extrapolated to include the management of older children and adults.

The evidence to support complementary therapies is limited, and the available randomized controlled trials are generally of poor quality. NICE states that 'there is insufficient evidence for complementary therapies (homeopathy, herbal medicine, massage, and food supplements) to make recommendations for their use in clinical practice' [NICE, 2007].

The Medicines and Healthcare products Regulatory Agency (MHRA) warns that the phrases 'natural', 'herbal', and 'derived from plants' do not necessarily mean that the product is 'safe'. Herbal medicines, like other medicines, can have adverse effects. They can also interact with other medicines, resulting in reduced or enhanced effects of the other medicines. For further information, see www.mhra.gov.uk/safetyinformation [MHRA, 2012].

A study was conducted at the paediatric dermatology clinic in Birmingham Children’s Hospital to determine whether herbal creams reported as being effective for the treatment of childhood atopic eczema contained corticosteroids. The parents of children who reported using herbal creams with good effect for atopic eczema (n = 19) were asked to submit the cream for analysis. Twenty four creams were analyzed [Ramsay et al, 2003]:

Five creams labelled Wau Wa contained clobetasol propionate. Further analysis suggested that it also contained about 20% proprietary Dermovate® cream in a paraffin base.

Two labelled Muijiza cream contained clobetasol propionate.

Thirteen of 17 unnamed creams contained corticosteroids: clobetasol proprionate (n = 4), clobetasol proprionate plus hydrocortisone (n = 1), betamethasone valerate (n = 2), clobetasone butyrate (n = 3), and hydrocortisone (n = 2); there was an unidentified peak in one cream.

All parents believed the creams were herbal, free from steroids, and safe for use on their children. Many of the creams cost over £25 and their use was often only reported when the parent could no longer afford to continue the treatment, resulting in worsening of their child’s eczema.

The authors concluded that there is an urgent need for tighter regulation of herbal creams and for increased public education about the potential dangers of alternative therapies.

Scenario: Infected eczema

Scenario: Infected eczema

1months3060monthsBoth

Treatment of infected eczema

How should I treat infected eczema?

If there are extensive areas of infected eczema, swab the skin and prescribe an oral antibiotic. Routine swabbing of skin that is not infected is not recommended.

Flucloxacillin is the first-line choice.

Prescribe erythromycin if the person has an allergy to penicillin or if there is known resistance to flucloxacillin. If the person has previously been unable to tolerate erythromycin because of nausea or cramps, consider using clarithromycin.

If the infection responds poorly to antibiotic treatment, prescribe an alternative antibiotic, if necessary, according to the swab results, or seek specialist advice.

If there are localized areas of infection, consider prescribing a topical antibiotic.

Creams or ointments containing antibiotics can be used as separate products or combined with a corticosteroid.

Advise that topical antibiotics should be used for no longer than 2 weeks.

An episode of infected eczema coexists with a flare and will require concomitant treatment at the appropriate treatment step. See Scenario: Mild eczema, Scenario: Moderate eczema, and Scenario: Severe eczema.

For more information on using antibiotics, see the prescribing information sections on Oral antibiotics and Topical antibiotics and antiseptics.

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], and have been extrapolated to include the management of older children and adults.

Oral antibiotics

Evidence to support the effectiveness of oral antibiotics in the treatment of visibly infected atopic eczema is limited due to a lack of high quality studies. However, clinical experience indicates that treatment of grossly infected skin is usually warranted [Hoare et al, 2000]. One randomized controlled trial (RCT) has reinforced the view that there is no benefit in treating skin with no signs of infection.

Choice of antibiotic [NICE, 2007]:

Flucloxacillin is the drug of choice for the treatment of atopic eczema that is visibly infected. It is a narrow-spectrum beta-lactam antibiotic with good activity against the most common causative pathogen, Staphylococcal aureus.

A macrolide is a suitable alternative to flucloxacillin if penicillins are contraindicated.

Erythromycin is commonly used, although nausea is a common adverse effect that may limit use.

Clarithromycin is an alternative to erythromycin that is reputed to cause less adverse effects [DTB, 1991].

Topical antibiotics

There is a lack of evidence from controlled trials to support the use of topical antibiotics to treat infected atopic eczema, with only one RCT investigating this. Data from trials that compared the use of topical antibiotic and corticosteroid combinations have not shown that addition of the antibiotic component provides benefit beyond that of a corticosteroid alone.

Despite the limited evidence to support their use, NICE considers that it is worth trialing these products on an individual basis if the area of infected eczema is localized. Their use should be restricted to a maximum of 2 weeks, however, because of concerns of bacterial resistance and the risks of sensitization.

Swabbing

Following advice from experts, CKS recommends swabbing all people with infected eczema before treatment with an oral antibiotic is started. This will allow for early detection of resistant staphylococcal species (including meticillin resistant Staphylococcus aureus [MRSA]) and beta haemolytic streptococci species, which may influence subsequent management.

Note that this recommendation is not in full agreement with the NICE or SIGN (Scottish Intercollegiate Guidelines Network) guideline development groups, who recommend swabbing only if there is recurrent infection or other reason to believe there is involvement of resistant or atypical organisms [NICE, 2007; SIGN, 2011].

The recommendation that routine swabbing of non–clinically infected skin should not be undertaken is derived from the SIGN guideline Management of atopic eczema in primary care [SIGN, 2011].

Prevention of infection

What treatment and advice can I give to reduce infection?

Prescribe new supplies of topical products (emollients and corticosteroids) for use after the infection has cleared, and advise the person to discard the old products.

Consider advising the use of a topical antiseptic preparation (for example chlorhexidine or triclosan) as an adjunct to standard treatment, to reduce the bacterial load in areas that are prone to infection.

Encourage continued maintenance of the skin by advising:

Avoidance of trigger factors.

Frequent and liberal use of emollients.

Appropriate use of topical corticosteroids.

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guidelines Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007] and Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011]. Recommendations from the NICE guideline have been extrapolated to include the management of older children and adults.

Topical corticosteroids and emollients should be discarded after the infection has cleared, as pathogens can contaminate them and survive in product packaging. This applies particularly to creams packaged in tubs and tubes, although the risk is probably less with pump-dispensers.

There is only limited evidence from controlled trials to support the effectiveness of topical antiseptics; however, they are recommended by NICE to reduce bacterial load in infection-prone areas on the basis of clinical experience. Routine use of emollients containing antiseptics is not recommended.

Encouraging the person to keep their skin in good condition by the appropriate use of emollients and other products, and the avoidance of trigger factors will help reduce the frequency of flares and infection.

Referral for infected eczema

When should I refer a person with infected eczema?

Admit to hospital if eczema herpeticum (widespread herpes simplex virus) is suspected.

Refer urgently (within 2 weeks) to a dermatologist if infected eczema has not responded to treatment.

Refer routinely to a dermatology department if:

The diagnosis is, or has become, uncertain.

Eczema is associated with severe and recurrent infections, especially deep abscesses or pneumonia.

Basis for recommendation

Basis for recommendation

These recommendations are based on the clinical guidelines Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], and have been extrapolated to include the management of older children and adults.

The NICE Guideline Development Group (GDG) could not find any clinical or cost-effective evidence in relation to referral and treatment outcomes for eczema. Therefore, these recommendations are based on referral advice from other guidance [Primary Care Dermatology Society and BAD, 2010], and the GDG's collective experience.

These recommendations are designed to reflect current clinical practice, ensuring that people who require a referral are referred more promptly and that inappropriate referrals are minimized.

Eczema herpeticum is potentially life-threatening and if suspected should prompt emergency admission for confirmation of the diagnosis and antiviral treatment [NICE, 2007].

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).

Stepped approach to treatment

NICE Stepped approach to treatment

The stepped approach, recommended by the National Institute for Health and Care Excellence (NICE), for the treatment of atopic eczema is shown in Table 1. Treatment can be stepped up or down according to the severity of the condition. Treatment of a flare will often require temporarily 'upping' the intensity of treatment (for example the strength of corticosteroid).

Non-sedating antihistamines, topical calcineurin inhibitors, phototherapy, and ciclosporin are less suitable for the acute treatment of flares.

Sedating antihistamines, bandaging, and oral corticosteroids are unsuitable for maintenance treatment.

Table 1 . Stepped treatment options for atopic eczema.
Mild atopic eczema Moderate eczema Severe eczema
Emollients Emollients Emollients
Mild potency topical corticosteroids Moderate potency topical corticosteroids Potent topical corticosteroids
Non-sedating antihistamines Non-sedating antihistamines Sedating antihistamines
Topical calcineurin inhibitors (tacrolimus or pimecrolimus)* Topical calcineurin inhibitors (tacrolimus or pimecrolimus)*
Bandages* Bandages*
Phototherapy
Oral corticosteroids
* Usually only prescribed by a specialist (for example a GP with a specialist interest in dermatology, a dermatologist, or a paediatrician). † Phototherapy is available in secondary care for the treatment of very severe eczema that has proved resistant to standard treatment. Systemic immunosuppressants (for example ciclosporin and azathioprine) are also available in secondary care for the same indication. ‡ Oral corticosteroids can be prescribed short-term in primary care for severe flares. Other systemic treatment suitable for maintenance of severe eczema (for example ciclosporin or azathioprine) require referral to secondary care.
Data from: [NICE, 2007]

Emollients

Available products

What emollient products are available?

There are a large number of emollients available in the UK. These include:

Non-proprietary and proprietary products.

Creams, ointments, gels, lotions, sprays, washes, and bath and shower additives.

For a complete list of all the emollient products available in the UK, see the British National Formulary (www.bnf.org).

Most emollient products are plain (that is, contain no active ingredients); however, some contain:

Urea (a keratin softener and hydrating agent), for example Aquadrate®, Balneum® Plus, Calmurid®, E45® Itch Relief Cream, and Eucerin® Intensive.

Antiseptic, for example Dermol® preparations (cream, lotion, shower, and bath emollient), Emulsiderm® liquid emulsion, and Oilatum Plus bath additive®.

Lanolin or lanolin derivatives, for example hydrous ointment, E45® cream and lotion, and Oilatum® emollient bath additive.

Lauromacrogols (which have local anaesthetic properties, and soothes and relieves itchy skin), for example Balneum® Plus and E45® Itch Relief Cream.

Emollients containing active ingredients are not generally recommended, but may be useful in some people (although they increase the risk of skin reactions).

All emollients are available on the NHS; however, some are classified as borderline substances and as such their prescriptions should be endorsed with 'ACBS' (Advisory Committee on Borderline Substances). These include Aveeno® products (bath oil, cream, and lotion) and E45® products (emollient bath oil, emollient wash cream, and lotion).

Preparations marked ‘ACBS’ are regarded as drugs when prescribed in accordance with the advice of the Advisory Committee on Borderline Substances for the clinical conditions listed.

Emollients are also available over-the-counter although availability may be limited.

Basis for recommendation

This information is from the British National Formulary [BNF 65, 2013].

Choice of product

Which emollient product should I prescribe?

Prescribe an emollient according to the dryness of the skin, and individual preference. The key to successful management is finding the correct balance between these factors.

In general, ointments should be used on dry skin, whereas creams and lotions can be used on less dry skin.

Ointments are usually poorly tolerated compared with cream; this may affect their acceptability, and hence compliance.

Experience has shown that proprietary products are often preferred to non-proprietary products; it may be a false economy to prescribe solely on the basis of price.

Do not prescribe aqueous cream as it is thought to cause a disproportionate amount of skin reactions.

Often, several different emollients will be required (for example for different areas of skin, different stages of flare, or for use in different locations).

Where possible, prescribe an emollient with a pump dispenser to minimize the risk of bacterial contamination.

For emollients that come in pots, advise that using a clean spoon or spatula (rather than fingers) to remove the emollient helps to minimize contamination.

Emollients containing active ingredients are not generally recommended, but may be useful in some people (although they increase the risk of skin reactions). Products containing:

Lauromacrogols are reputed to relieve itch.

Urea may improve skin hydration. It can enhance the moisture-retaining ability of emollients, thereby improving their efficacy.

Antiseptics (for example benzalkonium chloride) have a limited role in protecting skin which is prone to infection.

Prescribe emollients to replace soap in people with dry skin requiring treatment.

Ointments dissolved in hot water are suitable soap substitutes.

Bath additives and shower products are an option for people with extensive areas of dry skin.

The effectiveness and acceptability of a particular emollient may vary with time. If the person feels that a particular product has become unsuitable for them (or if they have developed sensitivity to it), prescribe an alternative emollient.

Basis for recommendation

These recommendations are consistent with the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], Best practice in emollient therapy published by the International Skin Care Nursing Group [Dermatology UK, 2007], and the guideline Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011]. Recommendations from the NICE guideline have been extrapolated to include the management of older children and adults.

Choice of emollient

There is no evidence from controlled trials to support the use of one emollient over another; therefore, recommendations are based on the known physiological properties of emollients together with pragmatic considerations.

Emollients with high lipid contents are thought to restore the skin barrier more effectively and more rapidly than those with lower lipid contents [Dermatology UK, 2007].

Patient preference is essential when selecting an emollient. NICE state that 'the correct emollient is the one that the child will use' and 'adherence to emollient treatment is the key to successful therapy for atopic eczema' [NICE, 2007]. NICE points out that branded products are generally preferred (at least by children) to generic products, and therefore generic products are not suitable as first-line treatment. They also state that as branded products tend to be similar in cost, the person should be prescribed the emollient of their choice.

Encouraging trials of different emollients encourages choice and should improve adherence to treatment.

CKS do not recommend the use of aqueous cream due to the increased risk of skin reactions associated with its use:

A clinical audit has revealed that the use of aqueous cream results in a significant proportion of people developing sensitization reactions, so it should be avoided [Cork et al, 2003].

The Medicines and Healthcare Products Regulatory Agency (MHRA) warns that aqueous cream may cause local skin reactions, such as stinging, burning, itching, and redness, when it is used as a leave-on emollient, especially in children with atopic eczema [MHRA, 2013]. The reactions, which are not generally serious, often occur within 20 minutes of application but can occur later, and may be due to sodium lauryl sulfate or other additives [MHRA, 2013].

Emollients with active ingredients

In general, the evidence to support the use of active ingredients in emollients is limited. Therefore, if used, these products should be trialled on an individual basis.

A systematic review [Hoare et al, 2000] identified one randomized controlled trial (RCT; n = 80) which found that an emollient containing urea was more effective than the emollient alone in the treatment of atopic eczema. Some experts suggest that it can enhance the moisture-retaining ability of emollients, thereby improving their efficacy [Moncrieff et al, 2013].

Evidence from several small RCTs using emollients combined with an antiseptic were of poor quality and subject to bias. However, experts suggest that intermittent use of antiseptic bath oils can reduce flares [Moncrieff et al, 2013].

CKS did not identify any trials that used emollients containing lauromacrogols as an intervention.

Use of emollients to replace soap

There are no published RCTs that have investigated the use of bath emollients and, unlike emollients designed to be left on the skin, there is no universal consensus on their benefit [DTB, 2007]. If bath emollients are used, it is essential that they do not replace standard emollients, and the person should be advised to continue using standard emollients in addition to any bath emollient product.

Quantity

How much emollient should I prescribe?

Once the preferred choice of emollient is known, prescribe large quantities, frequently. The amount of emollient prescribed will vary depending on the size of the person, and extent and severity of the eczema.

The quantities of emollient that should be prescribed to an adult with active atopic eczema are described in Table 1. For children, about half this amount is suitable.

The amount of emollient used should far exceed other topical treatments (for example corticosteroids), by a factor of at least ten.

Where possible, pump-dispensers should be prescribed when large quantities of cream or lotion are required.

Table 1 . Quantities of emollients that should be prescribed for adults with eczema, per week.
Area affected Creams and ointments (grams) Lotions (mL)
Face 15–30 100
Both hands 25–50 200
Scalp 50–100 200
Both arms or both legs 100–200 200
Trunk 400 500
Groin and genitalia 15–25 100
Data from: [Dermatology UK, 2007]
Basis for recommendation

These recommendations are consistent with the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [NICE, 2007] and Best practice in emollient therapy published by the International Skin Care Nursing Group [Dermatology UK, 2007]. The quantities of emollients recommended by CKS are based on the clinical experience of these Guideline Development Groups.

Emollients are typically under-prescribed and under-used, which will result in suboptimal treatment of dry skin and eczema, and may increase the occurrence of flares.

Pump-dispensers are more convenient than other containers and are less likely to become contaminated by potential pathogens.

Adverse effects

Skin reactions are the most common adverse effects of emollients. They are caused by sensitivity of the skin to additives in the emollient, such as perfumes, preservatives, and biological components such as lanolin (although newer hypoallergenic formulations of lanolin are less problematic).

If a skin reaction occurs, stop the product and use a different emollient. Aqueous cream is generally not recommended because of the high risk of developing skin reactions, especially in children.

If the person has had previous skin reactions to emollients, consider testing a small quantity on the skin before widespread application.

If sensitivity to emollients is a known problem, prescribe a cream with few additives, or an ointment to reduce the chance of a further reaction (ointments do not require preservatives and generally have less excipients).

The occlusive effect of ointments can cause folliculitis. If this occurs, stop the ointment (consider switching to a cream) and use an antibiotic if necessary.

Basis for recommendation

These recommendations are consistent with the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [NICE, 2007] and Best Practice in Emollient Therapy published by the International Skin Care Nursing Group [Dermatology UK, 2007].

Atopic people are thought to be more likely to react to additives found in emollients compared with the general population, so it is particularly important to anticipate potential sensitivity reactions and devise pragmatic strategies should this occur.

A clinical audit has revealed that the use of aqueous cream results in a significant proportion of people developing sensitization reactions, so it should be avoided [Cork et al, 2003]. A recent Medicines and Healthcare Product Regulatory Agency (MHRA) update warns that aqueous cream may cause local skin reactions, such as stinging, burning, itching, and redness, when it is used as a leave-on emollient, especially in children with atopic eczema [MHRA, 2013]. The reactions, which are not generally serious, often occur within 20 minutes of application but can occur later, and may be due to sodium lauryl sulfate or other additives [MHRA, 2013].

Usage instructions

What should I advise about how to use an emollient?

It is essential to provide instructions on the correct use of emollients, with clear demonstrations where appropriate.

Advise the person:

To use emollient liberally and frequently, even when their skin appears improved or is clear.

The frequency of application will vary depending on the person's condition and circumstances, but for very dry skin, application of an emollient every 2–3 hours should be considered normal.

To facilitate frequent application, the person should consider keeping separate packs of emollients at work or school.

It may be more convenient to use better tolerated products (such as creams and lotions) during the day, and use ointments at night.

It is particularly important to use emollients during or after bathing.

The approximate quantities of emollient that should be used by an adult in each application is given in Table 1.

About the effective application of emollients.

Emollients should be applied by smoothing them into the skin along the line of hair growth, rather than rubbing them in.

Creams and lotions are better for red, inflamed areas of skin.

Ointments are suitable for areas of dry skin that are not inflamed.

Table 1 . Number of grams of emollient that should be used in each application.
Area of skin Light dose regimen* (grams) Medium dose regimen (grams) High dose regimen (grams)
Arm 2 5 10
Chest 2 5 10
Abdomen 2 5 10
Upper back 2 5 10
Lower back 2 5 10
Thigh 2 5 10
Shin 2 5 10
Total 20 50 100
Note: one gram is equivalent to one pump of a dispenser, or approximately one level teaspoon. Two grams is approximately equivalent to one level desert spoon. Three grams is approximately equivalent to one level tablespoon. * Suitable for slightly dry skin, typically found in mild eczema. † Suitable for dry skin, typically found in moderate eczema. ‡ Suitable for very dry skin, typically found in severe eczema.
Data from: [Dermatology UK, 2007]
Basis for recommendation

These recommendations are consistent with the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], Best practice in emollient therapy published by the International Skin Care Nursing Group [Dermatology UK, 2007], and the guideline Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011].

NICE states that the effects of emollients are short-lived, although the precise duration of action is not quantified, and will be dependent on several factors such as the dryness of the skin and the type of emollient used (products with higher water contents lose effectiveness faster) [NICE, 2007].

Frequent application of emollients is therefore needed, and will require some practical forethought, such as keeping multiple containers of emollient in places other than the home.

Ointments, which can look and feel unpleasant and may stain clothes, may be better reserved for night-time use (a cream is less likely to be effective throughout the night).

The NICE Guideline Development Group believe that ointments are preferable for dry skin because they are more effective than creams, but creams are preferable on red, inflamed skin because the evaporation of water-based products cools the skin. This recommendation is based on clinical experience, rather than evidence from controlled trials or scientific studies.

Rubbing emollients into skin should be discouraged (based on clinical experience), because rubbing:

Introduces air into the emollient and reduces absorption.

Occludes or physically aggravates hair follicles, which may cause folliculitis (especially with ointments).

Stimulates blood circulation, which generates heat and may increase itch.

Advice for patients

It is essential to provide instructions on the correct use of emollients, with clear demonstrations where appropriate.

Advise the person:

On the appropriate use of emollients, including liberal and frequent use, even when the skin appears improved or clear.

On effective washing:

They should avoid the use of soaps, detergents, and bubble bath when washing; instead, a suitable soap substitute should be used, for instance an ointment dissolved in hot water (or lotion in warm water).

Skin should be gently dried after washing. An emollient can then be applied while the skin is still moist.

Bath additives and shower gels can be considered in people with extensive areas of dry skin; however, their use should supplement, not replace, emollients designed to be left on the skin.

That emollient products should not be shared with other people.

Emollients can become contaminated with bacteria. Pump dispensers minimize the risk of bacterial contamination. For emollients that come in pots, using a clean spoon or spatula (rather than fingers) to remove the emollient helps to minimize contamination.

To wait several minutes after application of an emollient before applying a topical corticosteroid.

Basis for recommendation

These recommendations are consistent with the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007], Best practice in emollient therapy published by the International Skin Care Nursing Group [Dermatology UK, 2007], and the guideline Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011].

Soaps have an emulsifying effect on the lipids of the skin and can be very damaging to people with eczema. Therefore, a soap substitute which hydrates the skin is required.

This may be a specialized washing product or a more general emollient (usually an ointment) mixed with warm water, according to the person's preference.

There are fears that using bath additives may encourage the person to reduce their use of emollients designed to be left on the skin, as these require time and effort to apply correctly, and may be unsightly. However, there is no research to verify this [DTB, 2007]. Nevertheless, it is prudent to advise the person to continue using the full emollient regimen.

Experts advise people to apply emollients immediately after showering or bathing (within 3 minutes), as this may trap moisture in the skin [Dermatology UK, 2007], although there are no studies to confirm this.

Topical corticosteroids

Available products

Topical corticosteroids are available in four potencies: mildly potent, moderately potent, potent, and very potent (see Table 1). All are available on the NHS with an FP10 form.

Table 1 . Topical corticosteroids listed in the British National Formulary.
Potency class Non-proprietary names and strengths Proprietary names Formulations
Mild* Hydrocortisone 0.1%, 0.5%, 1.0%, 2.5% Generic hydrocortisone, Dioderm®, Efcortelan®, Mildison® Creams and ointments
Moderate Alclometasone dipropionate 0.05% Modrasone® Cream and ointment
Betamethasone valerate 0.025% Betnovate-RD® Cream and ointment
Clobetasone butyrate 0.05% Eumovate® Cream and ointment
Fluocinolone acetonide 0.001% Synalar 1 in 4 dilution® Cream and ointment
Fluocortolone 0.25% Ultralanum Plain® Cream and ointment
Fludroxycortide 0.0125% Haelan® Cream and ointment
Potent Betamethasone dipropionate 0.05% Diprosone® Cream, ointment, and lotion
Betamethasone valerate 0.1% Generic betamethasone valerate, Betnovate® Cream, ointment, lotion, and scalp application. Foam (0.12%)
Diflucortolone valerate 0.1% Nerisone® Cream, ointment, and oily cream
Fluocinolone acetonide 0.025% Synalar® Cream, ointment, and gel
Fluocinonide 0.05% Metosyn® Cream and ointment
Fluticasone propionate 0.05% Cutivate® Cream and ointment
Hydrocortisone butyrate 0.1% Locoid® Cream, ointment, lipocream, and scalp application
Mometasone furoate 0.1% Elocon® Cream, ointment, and scalp application
Very potent Clobetasol propionate 0.05% Dermovate®, Clarelux® Cream, ointment, and scalp application
Diflucortolone valerate Nerisone Forte® Ointment and oily cream
* Hydrocortisone is available over-the-counter for the treatment of mild-to-moderate eczema not involving the face or genitals. † Very potent topical corticosteroids should usually only be prescribed by specialists.
Data from: [BNF 65, 2013]

Regimen for flares

What regimen of topical corticosteroid should I prescribe for a flare?

For normal skin on the body (not the face, genitals, or axillae), prescribe a strength of topical corticosteroid to match the severity of the eczema, to be used once a day for 7–14 days. The amount of corticosteroid required to treat a flare of eczema for 1 week in an adult is listed in Table 1 (about half of this is needed for a child).

For mild eczema — prescribe a mild topical corticosteroid.

For moderate eczema — prescribe a moderately potent corticosteroid.

For severe eczema — prescribe a potent topical corticosteroid.

If the response to once daily application is inadequate, increase to twice daily.

For flares on the face, genitals, or axillae, consider prescribing a mild potency topical corticosteroid and increase to a moderate potency corticosteroid only if necessary.

For moderate or severe flares on the face, genitals, or axillae, use a moderately potent corticosteroid for a maximum of 5 days. If this is insufficient, consider referral.

Prescribe an appropriate formulation for the person and their condition.

Creams are preferred by most people, especially when used on visible areas such as the face and hands.

Ointments provide the strongest emollient effect and may be more effective. However, they are greasy, and so may be more suitable for use at night.

Other formulations (such as for scalp applications) are suitable for specific areas of skin.

Table 1 . Quantities of topical corticosteroid per week suitable for the treatment of a flare of eczema in an adult.
Part of body Quantity of cream or ointment (grams)
Face and neck 15–30
Both hands 15–30
Scalp 15–30
Both arms 30–60
Both legs 100
Trunk 100
Groin and genitalia 15–30
Data from: [BNF 65, 2013]
Basis for recommendation

These recommendations are based on the clinical guidelines Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007; NICE, 2007] and Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011]. Recommendations from the NICE guideline have been extrapolated to include the management of older children and adults.

There is extensive evidence for the effectiveness of topical corticosteroids in the short-term treatment of atopic eczema; however there are few meaningful comparative trials on which to base the choice of topical corticosteroid. In the absence of clinical data, NICE advocates matching the severity of the eczema with the biochemical potency of the topical corticosteroid.

Selecting a topical corticosteroid that is acceptable to the person is important as it will encourage compliance with treatment [DTB, 2003].

A Technology Appraisal published by NICE recommends that 'where more than one alternative topical corticosteroid is considered clinically appropriate within a potency class, the drug with the lowest acquisition cost should be prescribed, taking into account pack size and frequency of application' [NICE, 2004b]. CKS recommends that cost should be taken into account, but not at the expense of preference.

The recommendation to prescribe a mild or moderate potency topical corticosteroid for use on the face, genitals, or axillae is based on SIGN [SIGN, 2011].

Regimen for maintenance

For the maintenance treatment of chronic eczema on the body (that is, skin other than the face, genitals, or axillae), consider one of the following two treatment options:

Step down treatment: prescribe the lowest potency topical corticosteroid that controls the eczema — typically this will be a potency class down from what is used during a flare (for example prescribe a moderate potency corticosteroid for maintenance in people who have severe flares).

Intermittent treatment

Weekend therapy: prescribe the usual topical corticosteroid, to be used on two consecutive days, once a week.

Twice weekly therapy: prescribe the usual topical corticosteroid, to be used twice a week (for example every 3–4 days).

Treatment should be continued indefinitely, although an occasional drug holiday is advisable when step down treatment is being used.

Chronic lichenified eczema may require prolonged treatment with a potent corticosteroid (for example for 4–6 weeks, depending on response). In some cases, a very potent corticosteroid may be indicated. Seek specialist advice before prescribing a very potent corticosteroid.

Use a mild topical corticosteroid for chronic eczema of the face, genitals, or axillae. If this is insufficient, consider referral.

Basis for recommendation

There is only limited evidence on the longer-term control of atopic eczema, although the National Institute for Health and Care Excellence (NICE) suggests that either a 'stepped' approach using a less potent corticosteroid, or 'weekend therapy' using the usual topical corticosteroid, are options for the treatment of chronic eczema. Both these strategies aim to control eczema whilst reducing adverse effects [NICE, 2007]:

Treatment of atopic eczema should follow a stepped approach. Emollients should always be used as minimal maintenance therapy, and their use should be continued during flares. Treatment should be stepped up or down according to severity and clinical response.

In children with frequent recurrent flares (two or three per month) of atopic eczema, topical corticosteroids can be used for two consecutive days per week as a strategy for flare prevention (weekend therapy). This strategy can only be started once a flare has been controlled.

There are few data on the adverse effects of prolonged intermittent topical corticosteroid treatment, but the frequent drug holidays are likely to ensure this regimen is well tolerated.

The recommendation to consider twice weekly maintenance therapy is based on advice in the guideline Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011].

The treatment of chronic lichenified eczema with topical corticosteroids is not addressed by NICE. However, the British Association of Dermatology recommend corticosteroid treatment of 'up to 4–6 weeks to gain initial remission of chronic eczema' [Primary Care Dermatology Society and BAD, 2006]. CKS interprets chronic eczema in this context to mean lichenified eczema, and acknowledges treatment of this length is often carried out in practice.

CKS recommends seeking specialist advice before prescribing very potent corticosteroids.

Prescribing issues

Prescribing issues

For detailed prescribing information on topical corticosteroids, including contraindications and cautions, adverse effects, monitoring, and information on prescribing to pregnant or breastfeeding women, see Scenario: Topical treatment in the CKS topic on Corticosteroids - topical (skin), nose, and eyes.

Advice for patients

Advise the person:

To apply the product sparingly to all the affected areas. Most products will be supplied with an information leaflet which will specify the number of finger-tip units (FTUs) needed to treat specific body areas.

One FTU is equivalent to about 500 mg and is sufficient to treat a skin area about twice that of the flat of the hand with the fingers together. The approximate amount that should be applied for each area of the body is listed in Table 1.

To use their emollient first, then wait several minutes before applying the topical corticosteroid (only after the emollient has been fully absorbed).

To apply their topical corticosteroid at a time of the day most convenient to them, for example just after the person has washed and applied emollients, and/or at night before sleep (this is particularly suitable if they are using ointments).

For flares of eczema, advise the person to:

Apply the topical corticosteroid no more than twice a day. For many people, once daily application will be sufficient, but this can be increased if there is an inadequate response.

Continue treatment for 48 hours after the eczema has cleared (if it has not improved after 2 weeks the person should return for further advice).

For maintenance of chronic eczema, advise the person to apply the topical corticosteroid once daily (on treatment days). The treatment should be continued indefinitely, although an occasional drug holiday is advisable when continuous treatment is being used.

Table 1 . Amount of topical corticosteroid to apply for one application.
Body area Number of finger-tip units* (FTUs) for adults and children
Face and neck Adult: 2.5 Children: 6–10 years: 2 3–5 years: 1.5 1–2 years: 1.5 3–6 months: 1
Arm and hand Adult: 4 Children:
6–10 years: 2.5 3–5 years: 2 1–2 years: 1.5 3–6 months: 1
Leg and foot Adult: 8 Children: 6–10 years: 4.5 3–5 years: 3 1–2 years: 2 3–6 months: 1.5
Trunk (front) Adult: 7 Children: 6–10 years: 3.5 3–5 years: 3 1–2 years: 2 3–6 months: 1
Trunk (back) including buttocks Adult: 7 Childre: 6–10 years: 5 3–5 years: 3.5 1–2 years: 3 3–6 months: 1.5
* One adult fingertip unit (FTU) is the amount of ointment or cream expressed from a tube with a standard 5mm diameter nozzle, applied from the distal crease to the tip of the index finger.
Data from: [MeReC, 1999]
Basis for recommendation

Finger-tip unit

This information is based on a MeRec Bulletin published by the National Prescribing Centre: Using topical corticosteroids in general practice [MeReC, 1999].

Combining topical corticosteroids and emollients

There are no controlled studies that have investigated the efficacy of combining topical corticosteroids and emollients. CKS recommends that when both treatments are being used, the emollient should be used first, followed by the topical corticosteroid, preferably after several minutes' wait.

The National Institute for Health and Care Excellence (NICE) states that 'a short interval (several minutes) should be left between application of a topical corticosteroid and an emollient, where practicable' [National Collaborating Centre for Women's and Children's Health, 2007]. Some experts advise that there should be a time interval of at least 30 minutes between the application of a topical corticosteroid and an emollient [Moncrieff et al, 2013]; however, this may not always be practical.

The clinical guideline Best practice in emollient therapy, published by the International Skin care Nursing Group [Dermatology UK, 2007] specifically states that emollients should be allowed to absorb before topical corticosteroids are applied (the skin should be moist or slightly tacky, but not slippery). This is because:

Well-moisturised skin may require a reduced amount of corticosteroid, and there is evidence from one study (type unspecified) that topical drugs may be more effective when used after emollients.

Application of a corticosteroid immediately on top of or before an emollient may lead to dilution of the product, and transfer corticosteroids to areas that do not require treatment.

Some experts recommend that the corticosteroid should be applied first. This is also a reasonable strategy provided the emollient is not applied too quickly (particularly on top of an ointment) and dilutes the corticosteroid.

Frequency of application

The frequency of application of topical corticosteroids has been the subject of a NICE Technology Appraisal. NICE identified evidence from 10 randomized controlled trials (RCTs) and found that overall, there was little difference in effectiveness between once-daily and more frequent application of topical corticosteroids, although a difference could not be ruled out [NICE, 2004b]. Taking into account cost-effectiveness information, NICE recommends that topical corticosteroids should be prescribed 'for application only once or twice daily'.

CKS recommends that, on a practical basis, most people should use topical corticosteroids once a day at first, and increase to twice a day only if they feel that the condition is not responding adequately. Once daily application has some potential advantages [Williams, 2007]:

It may cause less adverse effects. Although this has not been tested by RCTs, it is a reasonable assumption as the adverse effects of topical corticosteroids are known to be dose-dependent. Once-daily dosing may be particularly relevant for the control of chronic eczema.

It is more convenient for the person. In turn, this may improve compliance.

It is less expensive for the NHS (although this may not be true for some products licensed for once daily application,for example mometasone furoate).

Antihistamines

Antihistamines

Prescribing issues

Prescribing issues

If a non-sedating antihistamine is required, prescribe cetirizine, loratadine, or fexofenadine once daily.

Antihistamines are rarely indicated for pregnant women with eczema, but if required, loratadine is probably a safe option.

If a sedating antihistamine is required, prescribe chlorphenamine.

Chlorphenamine is not specifically licensed for pruritus, but is licensed for allergic conditions (including urticaria [a condition where itch is the predominant symptom]) in adults and children (older than 1 year of age).

Chlorphenamine may be considered in pregnancy, if necessary.

Basis for recommendation

The recommendation on non-sedating antihistamines is based on published review articles [Shamsi and Hindmarch, 2000; Wallace and Dykeqicz, 2008].

The recommendation on chlorphenamine is based on the manufacturer's Summary of Product Characteristics [ABPI Medicines Compendium, 2012].

The information on the use of loratadine and chlorphenamine in pregnancy is based on the UK Teratology Information Service (formerly the National Teratology Information Service) who states that in pregnant women [NTIS, 2009a; NTIS, 2009b]:

Loratadiine may be considered if a non-sedating antihistamine is required.

'Available data does not suggest an association between loratadine exposure and congenital malformations overall, although some increase in risk cannot be excluded because of the limited numbers of exposed pregnancies involved. An excess risk of hypospadias is suggested by some data, but this has not been confirmed'.

Chlorphenamine may be considered in the treatment of allergic disorders when the use of a sedating antihistamine is appropriate.

'There are reports of several thousand exposures to chlorphenamine during pregnancy with no evidence of an increased risk of fetal toxicity'.

Advice for patients

Advise that some people may experience sedation with antihistamines, which may affect their ability to drive. The sedative effects are enhanced when antihistamines are combined with alcohol.

Sedating antihistamines, including chlorphenamine, cause sedation in 10–50% of people, which can persist into the next day.

Non-sedating antihistamines are less likely to cause drowsiness and sedation (because these drugs penetrate the blood–brain barrier to a lesser extent than sedating antihistamines); however, the person should still be made aware of this potential adverse effect.

Basis for recommendation

This information is from the British National Formulary [BNF 65, 2013] and a Drug and Therapeutics Bulletin [DTB, 2002].

Oral corticosteroids

Oral corticosteroids

Prescribing issues

Prescribe a short course of an oral corticosteroid. There are no data from controlled trials, but 30 mg prednisolone taken in the morning for 1 week should be sufficient.

The frequent or prolonged use of systemic corticosteroids is associated with serious adverse effects, including growth retardation in children, diabetes mellitus, high blood pressure, and osteoporosis. However, these are unlikely to be a problem with a single course of prednisolone.

Consider referral:

If more than very occasional use is needed (for example more than one course in a year).

If oral corticosteroids are indicated in children aged less than 16 years.

It is not necessary to taper the dose when stopping a one-week course of prednisolone.

For detailed prescribing information on oral corticosteroids, including contraindications and cautions, adverse effects, and information on prescribing to pregnant or breastfeeding women, see the CKS topic on Corticosteroids - oral.

Basis for recommendation

These recommendations are based on the British National Formulary [BNF 65, 2013]. The suggested dose of prednisolone is based on expert opinion in a review article [Charman and Williams, 2003].

Advice for patients

Inform the person (or their carer) that oral corticosteroids will have an immediate impact on the eczema and make them feel better, but they are for exceptional use and cannot be prescribed very often.

Advise that the use of topical corticosteroids is not necessary while oral prednisolone is being used (although emollients should still be used). However, they should use potent topical corticosteroids on the affected areas when the oral course has finished, as there is a risk of rebound eczema occurring after discontinuation of prednisolone.

Basis for recommendation

This recommendation is based on expert opinion in a review article [Charman and Williams, 2003].

Oral antibiotics

Oral antibiotics

Prescribing issues for flucloxacillin

What issues should I consider before prescribing flucloxacillin?

Flucloxacillin is licensed for the treatment of infected skin conditions, including eczema. Use clinical judgement to determine the appropriate dose and duration.

The normal dosage for an adult is 250 mg, four times daily. This can be doubled if the skin looks very infected.

Treat for 1 week. This can be extended to 2 weeks if the initial response is inadequate.

Do not prescribe flucloxacillin to people with:

A true penicillin hypersensitivity. Gastrointestinal adverse effects alone (such as nausea, vomiting, or diarrhoea) do not constitute an allergy to penicillin.

History of penicillin-associated hepatic dysfunction.

Prescribe flucloxacillin with caution in people with a history of allergic reaction to penicillins, hypersensitivity to cephalosporins, hepatic impairment, and renal impairment.

The most common adverse effects include diarrhoea, nausea, vomiting, and skin rashes.

Suspect pseudomembranous colitis if a person develops severe diarrhoea during or after treatment with flucloxacillin. If suspected, stop treatment and admit the person (or seek specialist advice).

Anaphylaxis (delayed or immediate) is a serious, but rare adverse effect of flucloxacillin. If this occurs, stop flucloxacillin and give adequate medical treatment. See the CKS topic on Angio-oedema and anaphylaxis for more information.

Key drug interactions with flucloxacillin include:

Anticoagulants (for example warfarin) — monitor the prothrombin time or international normalised ratio more closely with the addition or withdrawal of flucloxacillin, as adjustment of the anticoagulant dose may be necessary. Prolongation of prothrombin time has been reported in people taking penicillins and warfarin concurrently.

Food — advise the person to take flucloxacillin one hour before food or on an empty stomach to optimise absorption of flucloxacillin. Despite the lack of evidence, it is thought that food can reduce the absorption of flucloxacillin.

Oral hormonal contraception — additional contraceptive precautions are not required during or after courses of penicillins. However, advise about the importance of correct contraceptive practice if there is vomiting or diarrhoea. For further information, see the section on Antibiotics in the CKS topic on Contraception - assessment.

Flucloxacillin and co-amoxiclav can be used by pregnant or breastfeeding women.

Basis for recommendation

This information is based on manufacturers' Summaries of Product Characteristics [ABPI Medicines Compendium, 2013b; ABPI Medicines Compendium, 2013c], the British National Formulary [BNF 65, 2013], a pharmaceutical database [Micromedex, 2011], and a reference textbook [Baxter and Preston, 2013]. In addition:

Contraindications and cautions

The Commission on Human Medicines (formerly the Committee on the Safety of Medicines) has advised that flucloxacillin has been associated with a very small increased risk of hepatic disorders, namely hepatitis and cholestatic jaundice. Hepatic reactions may occur up to 2 months after treatment with flucloxacillin has stopped. Risk factors include treatment for more than 14 days and increasing age. The dose and route of administration do not appear to affect this risk [CSM, 2004].

Adverse effects

The Faculty of Sexual and Reproductive Healthcare no longer advises that additional precautions are required when using combined hormonal contraception with antibiotics that are not enzyme inducers [FSRH, 2011].

Severe diarrhoea during or after treatment with antibiotics may be a sign of pseudomembranous colitis [Bartlett, 2002; Aronson, 2006; BNF 65, 2013]:

Pseudomembranous colitis is an acute, exudative colitis caused by Clostridium difficile, a Gram-positive toxin-releasing bacillus. It often follows antibiotic treatment and is usually of acute onset, but may become chronic.

It is a particular hazard of ampicillin, amoxicillin, co-amoxiclav, second- and third-generation cephalosporins, clindamycin, and quinolones.

Pregnancy

The UK Teratology Information Service states that penicillins may be used in pregnancy if considered appropriate. 'The available data do not provide any conclusive evidence of an increased risk of congenital malformations or fetal loss following maternal exposure to therapeutic doses of penicillins' [UKTIS, 2012a].

Penicillins are not known to be harmful in pregnancy [BNF 65, 2013].

Breastfeeding

Penicillin antibiotics (and cephalosporins) are the antibiotics of choice in breastfeeding women [Schaefer et al, 2007]. Only trace amounts of penicillins are found in breast milk [BNF 65, 2013].

Prescribing issues for erythromycin

What issues should I consider before prescribing erythromycin?

Erythromycin is licensed for skin and soft tissue infections.

It is usually prescribed at a dosage of 250 mg, four times daily, for 1 week.

The dose and duration can be doubled in severe infection.

Avoid erythromycin in people with severe hepatic impairment.

Prescribe erythromycin with caution in people with:

Hepatic impairment.

Renal impairment — give a maximum of 1.5 g daily in severe renal impairment due to the risk of ototoxicity.

Conditions which predispose to QT interval prolongation (such as electrolyte disturbances) and people taking drugs that prolong the QT interval (for example amiodarone, sotalol, terfenadine, and amisulpride). Quinolones can also prolong the QT interval, increasing the risk of Torsades de pointes arrhythmias.

Myasthenia gravis.

Common adverse effects include nausea, vomiting, or diarrhoea. However, erythromycin may also cause loss of appetite, stomach cramps, and decreased liver function.

Less common adverse effects include cardiac dysrhythmias and Torsades de pointes arrhythmias, pyloric stenosis (rare), hearing loss and ototoxicity (at high doses), myasthenia gravis, and pseudomembranous colitis.

Suspect pseudomembranous colitis if a person develops severe diarrhoea during or after treatment with erythromycin. If suspected, stop treatment and admit the person (or seek specialist advice).

Rarely, erythromycin may also cause anaphylaxis. If this occurs, stop erythromycin and give adequate medical treatment. See the CKS topic on Angio-oedema and anaphylaxis for more information.

Key drug interactions of erythromycin include:

Theophylline:

Check theophylline levels 48 hours after starting erythromycin and adjust the dose accordingly — theophylline clearance may be reduced by erythromycin, leading to toxicity (onset can be delayed for 2–7 days).

Monitor effects of erythromycin to ensure that they are adequate — serum concentration of erythromycin may also be reduced by theophylline.

Aminophylline would be expected to interact similarly.

Atorvastatin or simvastatin — stop atorvastatin or simvastatin for the duration of treatment with erythromycin. Erythromycin may inhibit the metabolism of atorvastatin and simvastatin via CYP3A4.

Carbamazepine — avoid concurrent use, unless carbamazepine levels can be closely monitored and suitable dose reductions made. Erythromycin raises carbamazepine levels by as much as 5-fold, which may result in carbamazepine toxicity (characterized by present as nausea, vomiting, ataxia, or drowsiness).

Drugs that prolong the QT interval (such as antiarrhythmics, antipsychotics, and tricyclic antidepressants) — seek advice from a microbiologist regarding a suitable alternative antibiotic. Macrolides can prolong the QT interval and concomitant use of two drugs that prolong the QT interval is not recommended.

Drugs that cause hypokalaemia — monitor potassium levels very closely, or seek advice from a microbiologist regarding a suitable alternative antibiotic. Macrolides can prolong the QT interval and hypokalaemia is a risk factor for QT interval prolongation. Drugs known to cause hypokalaemia include corticosteroids, loop and thiazide diuretics, salbutamol (and related bronchodilators), stimulant laxatives (in overuse or abuse), and theophylline.

Warfarin — monitor the international normalized ratio (INR) and adjust the warfarin dose accordingly. Occasionally and unpredictably, the effects of warfarin may be markedly increased by erythromycin.

Oral hormonal contraception — additional contraceptive precautions are not required during or after courses of macrolides. However, advise about the importance of correct contraceptive practice if there is vomiting or diarrhoea. For further information, see the section on Antibiotics in the CKS topic on Contraception - assessment.

Erythromycin is the macrolide of choice in pregnant and breastfeeding women.

Basis for recommendation

This information is based on the manufacturer's Summary of Product Characteristics [ABPI Medicines Compendium, 2010], the British National Formulary (BNF) [BNF 65, 2013], a pharmaceutical database [Micromedex, 2011], and a reference textbook [Baxter and Preston, 2013]. In addition:

Contraindications and cautions

Renal impairment — the recommendation to give a maximum of 1.5 g daily in severe renal impairment is based on the BNF [BNF 65, 2013].

Drug interactions

The Faculty of Sexual and Reproductive Healthcare no longer advises that additional precautions are required when using combined hormonal contraception with antibiotics that are not enzyme inducers [FSRH, 2011].

Pregnant and breastfeeding women

The UK Teratology Information Service states that if a macrolide is indicated, erythromycin is preferred because there is more documented experience with its use [UKTIS, 2012b]. The manufacturer advises that there is no evidence of hazard from erythromycin in human pregnancy [ABPI Medicines Compendium, 2010].

The textbook Drugs During Pregnancy and Lactation states that erythromycin is the macrolide of choice during breastfeeding [Schaefer et al, 2007] and the BNF advises that it is not harmful when used by breastfeeding women [BNF 65, 2013]. However, the manufacturer advises that since erythromycin is passed into breast milk, caution should be exercised when it is given to a nursing mother [ABPI Medicines Compendium, 2010].

Prescribing issues for clarithromycin

What issues should I consider before prescribing clarithromycin?

Clarithromycin is licensed for skin and soft tissue infection.

It is usually prescribed at a dosage of 250 mg, twice daily, for 1 week.

The dose and duration can be doubled in severe infection.

Avoid clarithromycin in people with severe hepatic impairment.

Prescribe clarithromycin with caution in people with:

Hepatic impairment.

Renal impairment:

Use half the normal dose in severe renal impairment (creatinine clearance less than 30 mL/min). Avoid Klaricid XL®(clarithromycin prolonged release once daily tablets) in people with creatinine clearance less than 30 mL/min.

Conditions which predispose to QT interval prolongation (such as electrolyte disturbances) and people taking drugs that prolong the QT interval (for example amiodarone, sotalol, terfenadine, and amisulpride). Quinolones can also prolong the QT interval, increasing the risk of Torsades de pointes arrhythmias.

Myasthenia gravis — macrolide antibiotics may aggravate the weakness of people with myasthenia gravis.

Adverse effects:

Clarithromycin is better tolerated than erythromycin, but nausea, vomiting, or diarrhoea can sometimes occur. Clarithromycin may also cause abdominal pain, abnormal taste (metallic or bitter), indigestion, and headache.

Suspect pseudomembranous colitis if a person develops severe diarrhoea during or after treatment with clarithromycin. If suspected, stop treatment and admit the person (or seek specialist advice).

Less common adverse effects include hepatitis, liver failure, toxic epidermal necrolysis, and Stevens-Johnson syndrome.

Rarely, clarithromycin may cause anaphylaxis. If this occurs, stop clarithromycin and give adequate medical treatment. See the CKS topic on Angio-oedema and anaphylaxis for more information.

Key drug interactions of clarithromycin include:

Theophylline — consider an interaction if any unexplained reduction in efficacy of clarithromycin, or adverse effects of theophylline occur. Theophylline clearance may be reduced by macrolides, leading to toxicity. The serum concentration of the macrolide may also be reduced by theophylline. This interaction is more likely with erythromycin, but may be seen with clarithromycin, especially if theophylline levels are at the higher end of the therapeutic range.

Aminophylline would be expected to interact similarly.

Atorvastatin or simvastatin — stop atorvastatin or simvastatin for the duration of treatment with clarithromycin. Clarithromycin may inhibit the metabolism of atorvastatin and simvastatin via CYP3A4.

Carbamazepine — consider reducing the dose of carbamazepine by 30–50% during treatment with clarithromycin, and advise the person to report symptoms of toxicity (such as dizziness, diplopia, ataxia, or confusion). Clarithromycin raises carbamazepine levels by 20 to 50%, despite dose reduction of up to 40%, leading to carbamazepine toxicity.

Drugs that prolong the QT interval (such as antiarrhythmics, antipsychotics, and tricyclic antidepressants) — seek advice from a microbiologist regarding a suitable alternative antibiotic. Macrolides can prolong the QT interval and concomitant use of two drugs that prolong the QT interval is not recommended.

Drugs that cause hypokalaemia — monitor potassium levels very closely, or seek advice from a microbiologist regarding a suitable alternative antibiotic. Macrolides can prolong the QT interval and hypokalaemia is a risk factor for QT interval prolongation. Drugs known to cause hypokalaemia include corticosteroids, loop and thiazide diuretics, salbutamol (and related bronchodilators), stimulant laxatives (in overuse or abuse), and theophylline.

Warfarin — monitor the international normalized ratio (INR) and adjust the warfarin dose accordingly. Occasionally and unpredictably, the effects of warfarin may be markedly increased by clarithromycin.

Oral hormonal contraception — additional contraceptive precautions are not required during or after courses of macrolides. However, advise about the importance of correct contraceptive practice if there is vomiting or diarrhoea. For further information, see the section on Antibiotics in the CKS topic on Contraception - assessment.

Erythromycin is the macrolide of choice in pregnant and breastfeeding women. Clarithromycin should only be considered if the woman cannot tolerate erythromycin and there is no suitable alternative.

Basis for recommendation

This information is based on the manufacturer's Summary of Product Characteristics [ABPI Medicines Compendium, 2013a], the British National Formulary (BNF) [BNF 65, 2013], a pharmaceutical database [Micromedex, 2011], and a reference textbook [Baxter and Preston, 2013]. In addition:

Contraindications and cautions

The recommendation to use half the normal dose in severe renal impairment is based on information from the BNF [BNF 65, 2013].

Since the dose of Klaricid XL® cannot be reduced from 500 mg daily, it is contraindicated in people with creatinine clearance less than 30 mL/min. All other formulations may be used in this group of people [ABPI Medicines Compendium, 2011].

Drug interactions

The Faculty of Sexual and Reproductive Healthcare no longer advises that additional precautions are required when using combined hormonal contraception with antibiotics that are not enzyme inducers [FSRH, 2011].

Pregnant and breastfeeding women

The UK Teratology Information Service states that erythromycin is the macrolide of choice in pregnancy. Newer macrolides (such as clarithromycin) should be reserved for compelling indications [UKTIS, 2012c].

The manufacturer advises that clarithromycin should be avoided in pregnant and breastfeeding women unless potential benefits outweigh the risks [ABPI Medicines Compendium, 2013a].

Advice for patients

Advise the person:

To continue treatment with topical corticosteroids and emollients while taking antibiotics.

That gastrointestinal adverse effects (such as nausea, vomiting, or diarrhoea) can sometimes occur with all antibiotics. However, these are particularly common with erythromycin. If the person experiences severe symptoms they should return for a trial of an alternative antibiotic (for example clarithromycin).

That additional contraceptive precautions are not required during or after courses of broad spectrum antibiotics. However, advise about the importance of correct contraceptive practice if there is vomiting or diarrhoea. For further information, see the section on Antibiotics in the CKS topic on Contraception - assessment.

Also advise people taking flucloxacillin that some people are allergic to penicillin antibiotics (including flucloxacillin). They should seek urgent medical advice if they develop a severe rash; there is swelling of the face, hands or feet; or they feel short of breath.

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007], the British National Formulary [BNF 65, 2013], and the Faculty of Sexual and Reproductive Healthcare [FSRH, 2011].

Topical antibiotics and antiseptics

Topical antibiotics and antiseptics

Prescribing issues

A range of topical antiseptics and antibiotics are available, either alone or combined with emollients or topical corticosteroids.

Antiseptics are used to lower bacterial load. They include:

Solutions of chlorhexidine salts and triclosan.

Potassium permanganate.

Antiseptics incorporated into emollients. See Available products.

The available topical antibiotics and corticosteroid/antibiotic combinations commonly used in eczema are listed in Table 1.

If a topical antibiotic alone is prescribed, continue treatment with a topical corticosteroid.

When prescribing combined products, generally the same issues and precautions apply as with topical corticosteroids alone. However, sensitization is more likely to occur, because of the inclusion of more additives. For more prescribing information on using topical corticosteroids, see the section on Topical corticosteroids.

Table 1 . Available topical antibiotic, combined antibiotic/corticosteroid, and antiseptic/corticosteroid products available for treating eczema.
Product type Active components Formulation (s) Proprietary name
Topical antibiotic alone Mupirocin Cream and ointment Bactroban®
Fusidic acid Cream and ointment Fucidin®
Topical antibiotic combined with corticosteroid Fusidic acid and hydrocortisone Cream and ointment Fucidin H®
Chlorquinaldol and hydrocortisone butyrate Cream and ointment Locoid C®
Clioquinol and betamethasone valerate Cream and ointment Betnovate-C®
Neomycin and betamethasone valerate Cream and ointment Betnovate-N®
Fusidic acid and betamethasone valerate Cream FuciBET®
Clioquinol and fluocinolone acetonide Cream and ointment Synalar-C®
Chlortetracycline and triamcinolone acetonide Ointment Aureocort®
Data from: [BNF 65, 2013]

Advice for patients

What information and advice should I give about topical antibiotics and antiseptics?

Advise the person:

Not to use topical antiseptics or antibiotics for more than 2 weeks (due to the increased risk of sensitization and bacterial resistance).

To stop using the product and return if their skin worsens; this may be a sign of sensitization or an indication that the product is not effectively treating the infection, and oral antibiotics may be required.

Basis for recommendation

These recommendations are consistent with the clinical guideline Atopic eczema in children published by the National Institute for Health and Care Excellence (NICE) [NICE, 2007].

Evidence

Evidence

Supporting evidence

Lifestyle strategies

Evidence on lifestyle strategies

The evidence of any benefit of lifestyle changes on eczema is weak. The studies in this area are considered to be of poor quality, and methodological difficulties such as poor concealment of randomization, lack of blinding, high drop-out rates, and short follow up without intent-to-treat analysis indicate that the results should be interpreted with caution.

Diet:

A Cochrane review (search date: March 2006) involving nine randomized controlled trials (RCTs [n = 421]) showed no benefit on eczema of modifying the diet of people without a proven allergy [Bath-Hextall et al, 2008].

One RCT (n = 62) in children with a proven egg allergy showed that children given an egg-free diet had a significantly increased chance of a reduction in the surface area affected by eczema compared with children given a normal diet over a 4-week period (relative risk (RR) 1.51, 95% CI 1.07 to 2.11).

One RCT (n = 85) comparing a few-foods diet with usual diet in unselected people found no significant difference in the severity of eczema.

Two RCTs (n = 48) comparing elemental diets with usual diet showed no difference in the severity of eczema symptoms and appearance.

Five RCTs (n = 224) looking at a milk- and egg-free diet in people without a proven allergy showed no benefit with respect to the severity of eczema symptoms.

A number of RCTs have failed to show any convincing benefit of zinc supplements (one RCT, n = 50), vitamin E supplements (one RCT, n = 96), or probiotic use (three RCTs) for the management of atopic eczema [NICE, 2007].

House-dust mite

A 2-month-long placebo-controlled RCT (n = 41; 2–10 years of age) found a significant reduction in the eczema severity score (SCORAD index) of children who underwent dust-mite avoidance measures (encasing mattresses, hot weekly washing of bed clothes, twice weekly vacuuming, removal of soft toys, and no pets) [NICE, 2007].

A further double-blind RCT (n = 60; 7–65 years of age) found a significant reduction in eczema severity with dust-mite avoidance strategies (GORE-TEX bedding system, carpet spraying, and high-filtration vacuuming) compared with placebo (mean difference 4.2, 95% CI 1.7 to 6.7, p = 0.008) [NICE, 2007].

In all studies, house-dust mite levels were significantly reduced. Achieving such low levels of house-dust mite may be impractical, time consuming, and unachievable in everyday life. In studies where house-dust mite levels were reduced by only 68%, no benefit was shown [Bath-Hextall and Williams, 2007].

Abrasive clothing

Two RCTs suggest that it is the texture of the fabric and not the actual type of fabric that is the important factor [Hoare et al, 2000].

Stress and itch-scratch cycle

In two RCTs, behavioural techniques combined with corticosteroid cream reduced global eczema scores by nearly 70% compared with 40% for corticosteroid cream alone. Despite shortcomings in the design of the studies, it seems likely that these results were significant [Hoare et al, 2000].

Emollients

Evidence on the effectiveness of emollients

There is a lack of evidence from controlled trials to support the effectiveness of emollients. Despite this, they are almost universally recommended as the first-line treatment for eczema and related dry skin conditions, on the basis of their historical usage and known physical properties, which give rise to a plausible mechanism of action. There is no evidence to support the use of one emollient over another, therefore, patient preference should guide choice.

A Health Technology Assessment (HTA) included a systematic review on the effectiveness of emollients [Hoare et al, 2000]. Despite rigorous searching methods, they identified only five randomized, double blinded studies of high enough quality to be included.

A study that compared a lotion with a cream (n = 50) found that both products improved symptom scores from baseline and there was no significant difference between the products. This result was similar to another study (n = 48) which found that two urea-containing products were equally effective.

One industry-funded study (n = 80) found that the addition of an emollient to a topical corticosteroid gave significantly better resolution of symptoms than the topical corticosteroid alone.

One study (n = 80) found a urea-containing emollient to be more effective than the vehicle alone.

The fifth study (n = 46) compared an emollient containing ammonium lactate with emollient alone. After 30 days, addition of the active ingredient was shown to reduce lichenification and erythema compared with the control.

The National Institute for Health and Care Excellence (NICE) clinical summary identified an RCT (n = 162) published subsequent to the HTA review [Grimalt et al, 2007]. It provided only limited evidence that the use of emollients can reduce the need for concomitant use of topical corticosteroids (that is, steroid-sparing effect).

NICE also identified three uncontrolled studies which evaluated the effectiveness of bath oils, including a large case series (n = 3566) [National Collaborating Centre for Women's and Children's Health, 2007]. Although symptoms improved with treatment, it is not possible to prove with certainty that the emollients were responsible for the beneficial effects. This lack of evidence from controlled trials, combined with a lack of consensus among experts, has led to the role of bath emollients for eczema to be questioned [DTB, 2007].

Topical corticosteroids

Evidence on topical corticosteroids

Effectiveness

Evidence on the effectiveness of topical corticosteroids

Historical use of topical corticosteroids has shown them to be an essential part of the management of active atopic eczema. However, high-quality placebo-controlled trials of their effectiveness are lacking. Studies comparing different topical corticosteroids with each other do not provide sufficient evidence to rank or preference them. Therefore, the choice of topical corticosteroid should be made by matching the severity of eczema with known biochemical potency of the drug.

A Health Technology Assessment (HTA) performed a systematic review that considered the effectiveness of topical corticosteroids [Hoare et al, 2000]. It identified a total of 83 usable randomized controlled trials (RCTs) that investigated some aspect of the effectiveness of topical corticosteroids in people with atopic eczema.

Topical corticosteroid compared with placebo

Most studies were performed in the period between the 1960s and 1980s, and were of poor methodological quality, often only reporting user preference data. Studies that did report clinical outcomes suggested that there was a large treatment effect.

Topical corticosteroids compared with other topical corticosteroids

The HTA identified 40 RCTs that compared one topical corticosteroid with another.

The RCTs rarely directly compared more than two products together, and there was a lack of a standard comparator of validated clinical potency.

Many trials were industry-sponsored and often, no evidence of difference was erroneously assumed to show equivalence.

The authors concluded that it was not possible to rank the effectiveness of the topical corticosteroids on the basis of this data.

Topical corticosteroids compared with other products

The HTA identified four RCTs in this category; however, methodological problems (for example blinding) and lack of placebo control arms, meant that useful conclusions could not be drawn.

Topical corticosteroids alone compared with topical corticosteroids combined with antibiotics

The HTA identified three RCTs that investigated the efficacy of topical corticosteroids alone compared with the same product combined with an antibiotic (these were betamethasone/fusidic acid, hydrocortisone/fusidic acid, and betamethasone/gentamycin). None of the studies found that the addition of an antibiotic improved clinical outcomes.

The National Institute for Health and Care Excellence's clinical guideline on Atopic eczema in children extracted RCTs with children as subjects from the HTA review, but considered other study designs where necessary (especially when considering safety).

The additional studies identified by NICE did not impact on the recommended management of atopic eczema (that is, there was no evidence that children should be treated differently).

NICE identified an RCT published subsequent to the HTA review (n = 207), which found that intermittent treatment with a potent corticosteroid was as effective as continuous treatment with a mild corticosteroid [Thomas et al, 2002].

Safety

Evidence on the safety of topical corticosteroids

Topical corticosteroids are probably safe when used for short periods at the correct dosage, with only a minimal risk of serious systemic adverse effects occurring. However, this risk is likely to rise with increasing dose, potency, and treatment duration. Localized adverse effects may occur but are usually reversible. These include skin atrophy, telangiectasia, and skin infection.

A Health Technology Assessment found no evidence of irreversible skin atrophy or pituitary suppression from a number of randomized controlled trials (RCTs) identified by the review process [Hoare et al, 2000]. However, the literature search was restricted to RCTs, and the large majority investigated only short-term use of corticosteroids (for example 4 weeks). Accordingly, these studies were too short in duration to detect long-term effects and were underpowered for detecting rare events.

A systematic review specifically investigated the safety of topical treatments for eczema, but found that the limited duration and quality of RCTs made it difficult to draw conclusions about topical corticosteroids [Callen et al, 2007].

The National Institute for Health and Care Excellence (NICE) clinical guideline on Atopic eczema in children widened their search to include other types of studies capable of detecting adverse effects (mainly in children) [National Collaborating Centre for Women's and Children's Health, 2007]. The following studies were described:

A post-marketing safety review (n = 202) followed children over a 10-year period and recorded skin irritation, depigmentation, and atrophy as the most common adverse effects. Rarer adverse effects included Cushing's syndrome and growth retardation.

Several case-series investigated the effect of topical corticosteroids on endogenous cortisol and adrenocorticotrophic hormone levels. Results were conflicting, but there was biochemical evidence of adrenal suppression in some individuals.

Two cross-sectional studies noted some evidence of adrenal suppression in children treated with potent and very potent corticosteroids, but not with moderate or mild corticosteroids.

A retrospective observational study investigated adults (n = 605) and children (n = 666) who had received topical corticosteroids for at least 6 months. Adverse effects were relatively rare and included skin atrophy and telangiectasia (on the cheeks). These tended to be related to the amount of topical corticosteroid used.

NICE concluded that short-term use of topical corticosteroids of any potency did not cause significant suppression of adrenal function. There was limited evidence that longer-term use could result in adrenal suppression, but the clinical implications of this are not clear.

Other adverse effects that have been described by the studies reported by NICE were localized in nature and included transient stinging on application, hypertrichosis, telangiectasia, skin atrophy (especially of the antecubital and popliteal fossa), acne, folliculitis, infection, and steroid-induced contact dermatitis.

Frequency of application

Evidence on the frequency of application of topical corticosteroids

Short-term randomized controlled trials (RCTs), generally of poor methodological quality, have not consistently shown that twice-daily application is superior to once-daily application. In the absence of better quality and longer-term studies, topical corticosteroids should be applied no more than once or twice a day, in accordance with national guidelines.

The optimal frequency of application of antibiotics was the subject of a Technology Appraisal published by the National Institute for Health and Care Excellence (NICE) [NICE, 2004b]. It considered evidence from a systematic review and meta-analysis performed by an earlier Health Technology Assessment (HTA) [Hoare et al, 2000], and seven additional RCTs not included in the earlier HTA.

The included studies were all RCTs which were considered to be of poor methodological quality. Most (n = 8) compared once-daily application of a potent topical corticosteroid with more frequent application of either the same product or a different product. One study also investigated a moderate potency corticosteroid, and one investigated a very potent corticosteroid.

Most studies did not report the setting, and no study appeared to be in a primary care setting. All of the trials were short-term in duration, lasting between 1 and 4 weeks.

The studies reported different outcomes, and none used quality of life or individual preference data. The authors of the Technology Appraisal did not attempt to combine the studies in a meta-analysis because of this and other heterogeneity in the data.

Results

The HTA reported (from their meta-analysis) that there was no significant difference between once daily and more frequent application, although a difference could not be excluded.

The NICE Technology Appraisal reported that, overall, there was little difference between once-daily and more frequent application of topical corticosteroids.

Some statistically significant differences were found in some studies, but these were inconsistent both between studies and within the same study (for example the physician may have reported improvement, but not the person with eczema).

Mometasone furoate once-daily was found to be superior for some outcomes to twice-daily application of betamethasone valerate or hydrocortisone butyrate, although a third trial reported no significant difference with twice-daily betamethasone dipropionate. However, these trials were industry-sponsored, and NICE considered them to have methodological shortfalls, particularly in their blinding procedures.

Adverse effects were reported by some studies, and there appeared to be little difference between once-daily and twice-daily applications. However, longer-term studies would be required to ascertain the most clinically important adverse effects (for example skin atrophy).

Conclusions

The HTA summarized that 'based on the evidence, it would be justifiable to use once daily-corticosteroids as a first step in all patients with atopic eczema'. Once-daily application of topical corticosteroids has also been endorsed by other authors [Green et al, 2004; Williams, 2007].

The authors of the NICE Technology Appraisal concluded that 'there was no compelling evidence of a clinically significant difference between once-daily application and more frequent application of topical corticosteroids in terms of their effectiveness, patient satisfaction, adverse effects, concordance with therapy, and the number of follow-up visits required'. However, when cost-effectiveness data were considered, it was concluded that the 'greater likelihood of treatment success (that is, successfully treated flare-up) would be of sufficient value (in terms of patient benefit, and avoided GP consultations, referrals to specialists or prescribing more expensive products) to regard twice-daily application as cost-effective'.

Prevention of flares

Evidence on using topical corticosteroids to prevent flares

There is evidence from four randomized controlled trials (RCTs) that intermittent treatment with a potent corticosteroid when eczema is controlled can significantly reduce the recurrence of flares, with a low risk of adverse effects.

The Clinical Guideline by the National Institute for Health and Care Excellence (NICE) identified three RCTs that compared intermittent treatment with a potent corticosteroid (fluticasone propionate) with a placebo control [National Collaborating Centre for Women's and Children's Health, 2007].

One trial of adults and children (n = 348) stabilized the participants with fluticasone propionate and then randomized them to receive the drug intermittently (four times a week for 4 weeks, then twice a week for 16 weeks) or vehicle only (placebo).

The relapse rate was 27% in the treatment group compared with 66% in the placebo group. This was a significant difference (OR 8.1, 95% CI 4.3 to 15.2, p < 0.001).

The median time of relapse in the placebo group was 5.1 weeks; this could not be quantified in the fluticasone group because most people were controlled at the end of the follow-up period.

There was no evidence of skin atrophy in either group.

A double-blind RCT (n = 376 adults) used fluticasone dipropionate to control symptoms and then randomized the participants to receive fluticasone propionate cream 0.05%, fluticasone propionate ointment 0.005%, or vehicle alone on 2 consecutive days a week for 16 weeks.

Both the cream (hazard ratio [HR] 5.8, 95% CI 3.1 to 10.8) and the ointment (HR 1.9; 95% CI 1.2 to 3.2) reduced the chance of flares compared with placebo.

Median time to relapse was longer than the 16 week follow up with both fluticasone propionate cream and ointment compared with 6.1 weeks for the vehicle alone.

There were three individuals reported as having signs of skin atrophy during the stabilization phase.

A double-blind RCT (n = 54 adults) also reported a lower relapse rate with fluticasone propionate 0.005% ointment applied twice a week compared with vehicle alone.

An RCT randomized children (n = 207) who suffered mild or moderate flares of eczema, to receive betamethasone valerate 0.1% on 3 consecutive days, or hydrocortisone continuously during their flare [Thomas et al, 2002]. Both treatments were found to be equally effective, and no serious adverse effects were reported.

Antihistamines

Evidence on the effectiveness of antihistamines

There is a lack of consistent, long-term, high-quality, trial evidence to support the use of antihistamines in people with eczema. However, clinical experience suggests that sedating antihistamines may be useful in people who suffer sleep loss during flares, and non-sedating antihistamines may prevent itching and urticaria. If itch is a dominant feature, a trial of antihistamines can be considered on an individual basis.

A Health Technology Assessment (HTA) identified 21 randomized controlled trials (RCTs) where antihistamines were used as an intervention for atopic eczema [Hoare et al, 2000]. The general quality of the studies was described as poor, with many opting for a crossover design, which is not suitable for short-term studies of this nature.

Four RCTs were found which compared sedating antihistamines with placebo; none reported significant global improvement or reduction in itch. However, the studies might have been underpowered.

The studies of non-sedating antihistamines were comparative in nature. The authors of the review commented that these were very difficult to interpret in the absence of adequate placebo-controlled trials. In addition, some studies used doses far in excess of the licensed dose.

The clinical guideline from the National Institute for Health and Care Excellence (NICE) identified three placebo-controlled studies in children that were published subsequent to the HTA review [National Collaborating Centre for Women's and Children's Health, 2007].

One study (n = 151) compared chlorphenamine (a sedating antihistamine) with placebo. After 4 weeks, there was no significant difference between the groups in any outcome measure.

An RCT (n = 50) found no difference between loratadine and placebo after 15 days of treatment.

The Early Treatment of the Atopic Child study was a large RCT (n = 795) that investigated the preventative effect of cetirizine in atopic children, including a subgroup of children with atopic eczema.

Children who received cetirizine used less moderate or potent topical corticosteroids (mean 25.8% of days compared with 35.1% for placebo, p = 0.014). Symptom outcomes were not significantly different between the groups.

There was no significant difference in adverse effects or laboratory tests between children receiving placebo or cetirizine.

The HTA concluded that 'the current RCT evidence does not support the routine use of antihistamines in atopic eczema'.

NICE commented that there was a lack of good-quality controlled trials investigating the effectiveness of antihistamines in children with eczema, and the available data was often conflicting. In the absence of good trial evidence, NICE recommend that clinical experience still supports the use of antihistamines in some situations, although this should not be routine. To assess whether treatment is of benefit, it is worth considering a short trial on an individual basis.

Oral corticosteroids

Evidence on the effectiveness of oral corticosteroids

There are no usable trial data to support the effectiveness of oral corticosteroids in the treatment of atopic eczema. However, in clinical practice, oral prednisolone produces a large treatment effect and is a useful drug for the treatment of severe flares when other options have not proved effective. Long-term or frequent use should be avoided because of the risks of adverse effects and rebound eczema.

A Health Technology Assessment (HTA) stated that 'large treatment effects are observed in studies that compare systemic steroids versus placebo in terms of short-term disease response'. However, the review did not state the nature of these studies, but commented that there was a lack of longer-term studies or comparative studies with other systemic drugs such as ciclosporin [Hoare et al, 2000].

A systematic review of treatments for severe eczema failed to identify any randomized controlled trials (RCTs) that investigated the effectiveness or safety of oral prednisolone for atopic eczema [Schmitt et al, 2007].

The clinical guideline from the National Institute for Health and Care Excellence (NICE) failed to identify any controlled studies that investigated the safety or effectiveness of oral prednisolone for atopic eczema [National Collaborating Centre for Women's and Children's Health, 2007].

The authors did identify a small RCT (n = 27) that found that beclometasone dipropionate (used both orally and nasally) improved symptoms of eczema compared with placebo. However, this is not common clinical practice, and is not a licensed use.

A small case series and one case report were also identified which suggested that systemic corticosteroids are effective for atopic eczema.

Antibiotics and antiseptics

Evidence on the effectiveness of antibiotics and antiseptics

Evidence from controlled trials to support the use of oral antibiotics, topical antibiotics, or antiseptics is lacking. However, clinical experience suggests that grossly infected eczema will benefit from treatment with an oral antibiotic (or topical antibiotic if infection is localized). Antiseptics can be considered for use as adjuncts to other treatments. There is no justification to treat eczema with no signs of infection with an antibiotic or antiseptic.

Oral antibiotics

A Health Technology Assessment (HTA) performed a systematic review and identified three randomized controlled trials (RCTs) that evaluated the effectiveness of oral antibiotics in the treatment of atopic eczema [Hoare et al, 2000]. The quality of reporting of these studies was described as disappointing.

One study (n = 42) compared two salt forms of erythromycin and no conclusions could be drawn.

One double-blind study (n = 33) found cefadroxil to be more effective than placebo in children with visible eczema. However, the quality of reporting was poor and it did not use intent-to-treat analysis.

One double-blind study (n = 50) randomized children with atopic eczema but with no clinical signs of infection, to receive flucloxacillin or placebo. At follow up there was no difference in clinical or microbiological outcomes between the groups.

Topical antibiotics and antiseptics

The HTA review identified six RCTS that investigated the effectiveness of topical products designed to reduce infection in people with eczema. The studies were generally of poor quality.

Only one study (n = 49) investigated a topical antibiotic (mupirocin) compared with placebo. There was some evidence that the antibiotic was effective, but methodological shortcomings in the trial design (a crossover study) means this result should be treated with caution.

The other five studies investigated various antiseptic formulations (often combined with emollient) and found some favourable outcomes. However, the quality of these studies was poor, and the possibility of bias means they should be regarded with caution.

The clinical guideline by the National Institute of Health and Clinical Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007] identified several other studies investigating the role of antiseptic products. However, these were uncontrolled case-series and reports, and firm conclusions could not be drawn.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of eczema, with additional searches for evidence in the following areas:

Use of corticosteroids in eczema

Search dates

February 2008 - January 2013

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

exp Eczema/, eczema.tw., atopic eczema.tw., exp Dermatitis, Atopic/, atopic dermatitis.tw.

corticosteroid$.tw.

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSh subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Topic specific literature search sources

Allergy UK

American Academy of Dermatology

Australasian College of Dermatologists

British Association of Dermatologists

DermNet NZ

European Dermatology Forum

Joint Council of Allergy, Asthma and Immunology

Primary Care Dermatology Society

Scottish Dermatological Society

World Allergy Organization

Sources of guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

Royal College of Physicians

Royal College of General Practitioners

Royal College of Nursing

NICE Evidence

Health Protection Agency

World Health Organization

National Guidelines Clearinghouse

Guidelines International Network

TRIP database

GAIN

NHS Scotland National Patient Pathways

New Zealand Guidelines Group

Agency for Healthcare Research and Quality

Institute for Clinical Systems Improvement

National Health and Medical Research Council (Australia)

Royal Australian College of General Practitioners

British Columbia Medical Association

Canadian Medical Association

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Singapore Ministry of Health

National Resource for Infection Control

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

Driver and Vehicle Licensing Agency

NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

The Cochrane Library :

Systematic reviews

Protocols

Database of Abstracts of Reviews of Effects

Medline (with systematic review filter)

EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library :

Central Register of Controlled Trials

Medline (with randomized controlled trial filter)

EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Bandolier

Drug & Therapeutics Bulletin

TRIP database

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

Patient experiences

Healthtalkonline

BMJ - Patient Journeys

Patient.co.uk - Patient Support Groups

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

British National Formulary (BNF)

electronic Medicines Compendium (eMC)

European Medicines Agency (EMEA)

LactMed

Medicines and Healthcare products Regulatory Agency (MHRA)

REPROTOX

Scottish Medicines Consortium

Stockley's Drug Interactions

TERIS

TOXBASE

Micromedex

UK Medicines Information

References

ABPI Medicines Compendium (2010) Summary of product characteristics for Erythrocin 500 tablets. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2011) Summary of product characteristics for Klaricid XL 500mg tablets. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2012) Summary of product characteristics for Piriton Tablets. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2013a) Summary of product characteristics for Klaricid 500mg tablets. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2013b) Summary of product characteristics for Floxapen Capsules 500mg. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2013c) Summary of product characteristics for Augmentin 625mg Tablets. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

Akdis, C.A., Akdis, M., Bieber, T. et al. (2006) Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report. Allergy 61(8), 969-987. [Abstract] [Free Full-text]

Aronson, J.K. (Ed.) (2006) Meyler's side effects of drugs. The international encyclopedia of adverse drug reactions and interactions. Volume 1: A-B. 15th edn. Amsterdam: Elsevier.

Ashcroft, D.M., Chen, L.C., Garside, R. et al. (2007) Topical pimecrolimus for eczema (Cochrane Review). The Cochrane Library. Issue 4. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]

Baron, S.E., Cohen, S.N., Archer, C.B. and British Association of Dermatologists and Royal College of General Practitioners (2012) Guidance on the diagnosis and clinical management of atopic eczema. Clinical and Experimental Dermatology 37 Suppl 1(), 7-12. [Abstract] [Free Full-text]

Bartlett, J.G. (2002) Clinical practice. Antibiotic-associated diarrhea. New England Journal of Medicine 346(5), 334-339.

Bath-Hextall, F. and Williams, H. (2007) Eczema (atopic). Clinical EvidenceBMJ Publishing Ltd. www.clinicalevidence.com

Bath-Hextall, F., Delamere, F.M. and Williams, H.C. (2008) Dietary exclusions for established atopic eczema (Cochrane Review). The Cochrane Library. Issue 1. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]

Baxter, K. and Preston, C.L. (Eds.) (2013) Stockley's drug interactions 2013: pocket companion. London: Pharmaceutical Press.

Beltrani, V.S. and Boguneiwicz, M. (2003) Atopic dermatitis. Dermatology Online Journal 9(2), 1. [Free Full-text]

BNF 65 (2013) British National Formulary. 65th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.

Buddenkotte, J., Maurer, M. and Steinhoff, M. (2010) Histamine and antihistamines in atopic dermatitis. Advances in Experimental Medicine and Biology 709(), 73-80. [Abstract]

Callen, J., Chamlin, S., Eichenfield, L.F. et al. (2007) A systematic review of the safety of topical therapies for atopic dermatitis. British Journal of Dermatology 156(2), 203-221. [Abstract] [Free Full-text]

Charman, C. and Williams, H. (2003) The use of corticosteroids and corticosteroid phobia in atopic dermatitis. Clinics in Dermatology 21(3), 193-200.

Cork, M.J., Timmins, J., Holden, C. et al. (2003) An audit of adverse drug reactions to aqueous cream in children with atopic eczema. Pharmaceutical Journal 271(7277), 747-748.

CSM (2004) Reminder: flucloxacillin and serious hepatic disorders. Current Problems in Pharmacovigilance 30(Oct), 9. [Free Full-text]

Dermatology UK (2007) Best practice in emollient therapy: a statement for healthcare professionals. Dermatology UK Ltd. [Free Full-text]

DermNet NZ (2012a) The causes of atopic dermatitis (eczema). New Zealand Dermatological Society Incorporated. www.dermnetnz.org [Free Full-text]

DermNet NZ (2012b) Complications of atopic dermatitis. New Zealand Dermatological Society Incorporated. www.dermnetnz.org [Free Full-text]

DermNet NZ (2013) Atopic eczema. New Zealand Dermatological Society Incorporated. www.dermnetnz.org [Free Full-text]

DTB (1991) Clarithro- and azithromycin: better erythromycins? Drug & Therapeutics Bulletin 29(26), 101-102.

DTB (2002) Oral antihistamines for allergic disorders. Drug & Therapeutics Bulletin 40(8), 59-62. [Abstract]

DTB (2003) Topical steroids for atopic dermatitis in primary care. Drug & Therapeutics Bulletin 41(1), 5-8. [Abstract]

DTB (2007) Bath emollients for atopic eczema: why use them? Drug & Therapeutics Bulletin 45(10), 73-75. [Abstract]

FSRH (2011) Drug interactions with hormonal contraception. Faculty of Sexual and Reproductive Healthcare. www.fsrh.org [Free Full-text]

Green, C., Colqitt, J.L., Kirby, J. et al. (2004) Clinical and cost-effectiveness of once-daily versus more frequent use of same potency topical corticosteroids for atopic eczema: a systematic review and economic evaluation. Health Technology Assessment 8(47), 1-134. [Free Full-text]

Greenhawt, M. (2010) The role of food allergy in atopic dermatitis. Allergy and Asthma Proceedings 31(5), 392-397. [Abstract]

Grimalt, R., Menguaud, V. and Cambazard, F. (2007) The steroid-sparing effect of an emollient therapy in infants with atopic dermatitis: a randomized controlled study. Dermatology 214(1), 61-67. [Abstract]

Hoare, C., Li Wan Po, A. and Williams, H. (2000) Systematic review of treatments for atopic eczema. Health Technology Assessment 4(37), 1-191. [Free Full-text]

Holden, C.A. and Parish, W.E. (1998) Atopic dermatitis. In: Champion, R.H., Burton, J.L., Burns, D.A and Breathnach, S.M. (Eds.) Rook/Wilkinson/Ebling textbook of dermatology: volume 1. 6th edn. Oxford: Blackwell Science. Chapter 18. 681-708.

Iskedjian, M., Piwko, C., Shear, N.H. et al. (2004) Topical calcineurin inhibitors in the treatment of atopic dermatitis: a meta-analysis of current evidence. American Journal of Clinical Dermatology 5(4), 267-279. [Abstract]

Langan, S.M., Thomas, K.S. and Williams, H.C. (2006) What is meant by a "flare" in atopic dermatitis? A systematic review and proposal. Archives of Dermatology 142(9), 1190-1196. [Abstract] [Free Full-text]

Mason, R. (2008) Fabrics for atopic dermatitis. Journal of Family Health Care 18(2), 63-65. [Abstract]

MeReC (1999) Using topical corticosteroids in general practice. MeReC Bulletin 10(6), 21-24. [Free Full-text]

MHRA (2012) Using herbal medicines safely. Medicines and Healthcare products Regulatory Agency. www.mhra.gov.uk [Free Full-text]

MHRA (2013) Aqueous cream: may cause skin irritation, particularly in children with eczema, possibly due to sodium lauryl sulfate content. Drug Safety Update 6(8), A2. [Free Full-text]

Micromedex (2011) MICROMEDEX [CD-ROM]Thomson Healthcare.

Moncrieff, G., Cork, M., Lawton, S. et al. (2013) Use of emollients in dry-skin conditions: consensus statement. Clinical and Experimental Dermatology 38(3), 231-238. [Abstract]

National Collaborating Centre for Women's and Children's Health (2007) Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years (full NICE guideline). . Clinical guideline 57. National Institute for Health and Care Excellence. www.nice.org.uk [Free Full-text]

NICE (2004a) Tacrolimus and pimecrolimus for atopic eczema (NICE technology appraisal 82). National Institute for Health and Care Excellence. www.nice.org.uk [Free Full-text]

NICE (2004b) Frequency of application of topical corticosteroids for atopic eczema (NICE technology appraisal 81). National Institute for Health and Care Excellence. www.nice.org.uk [Free Full-text]

NICE (2007) Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years (NICE guideline). . Clinical guideline 57. National Institute for Health and Care Excellence. www.nice.org.uk [Free Full-text]

NICE (2011) Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community settings (NICE guideline). . Clinical guideline 116. National Institute for Health and Care Excellence. www.nice.org.uk [Free Full-text]

NTIS (2009a) Chlorphenamine in pregnancy. TOXBASENational Teratology Information Service. www.toxbase.org

NTIS (2009b) Use of loratadine in pregnancy. TOXBASENational Teratology Information Service. www.toxbase.org

Osman, M., Tagiyeva, N., Wassall, H.J. et al. (2007) Changing trends in sex specific prevalence rates for childhood asthma, eczema, and hay fever. Pediatric Pulmonology 42(1), 60-65. [Abstract] [Free Full-text]

Peate, I. (2011) Eczema: causes, symptoms and treatment in the community. British Journal of Community Nursing 16(7), 324-331. [Abstract]

Primary Care Dermatology Society and BAD (2006) Guidelines for the management of atopic eczema. British Association of Dermatologists. www.bad.org.uk

Primary Care Dermatology Society and BAD (2010) Guidelines for the management of atopic eczema. British Association of Dermatologists. www.bad.org.uk [Free Full-text]

Ramsay, H.M., Goddard, W., Gill, S. and Moss, C. (2003) Herbal creams used for atopic eczema in Birmingham, UK illegally contain potent corticosteroids. Archives of Disease in Childhood 88(12), 1056-1057. [Abstract] [Free Full-text]

Schaefer, C., Peters, P. and Miller, R.K. (Eds.) (2007) Drugs during pregnancy and lactation: treatment options and risk assessment. 2nd edn. Oxford: Academic Press.

Schmitt, J., Schäkel, K., Schmitt, N. and Meurer, M. (2007) Systemic treatment of severe atopic eczema: a systematic review. Acta Dermato-Venereologica 87(2), 100-111. [Abstract] [Free Full-text]

Sehra, S., Tuana, F.M., Holbreich, M. et al. (2008) Scratching the surface: towards understanding the pathogenesis of atopic dermatitis. Critical Reviews in Immunology 28(1), 15-43. [Abstract]

Shamsi, Z. and Hindmarch, I. (2000) Sedation and antihistamines: a review of inter-drug differences using proportional impairment ratios. Human Psychopharmacology 15(Suppl 1), S3-S30. [Abstract]

Shamssain, M. (2007) Trends in the prevalence and severity of asthma, rhinitis and atopic eczema in 6- to 7- and 13- to 14-yr-old children from the north-east of England. Pediatric Allergy and Immunology 18(2), 149-153. [Abstract]

SIGN (2011) Management of atopic eczema in primary care. Scottish Intercollegiate Guidelines Network. www.sign.ac.uk [Free Full-text]

Simpson, E.L. (2010) Atopic dermatitis: a review of topical treatment options. Current Medical Research and Opinion 26(3), 633-640. [Abstract]

Thomas, K.S, Armstrong, S, Avery, A. et al. (2002) Randomised controlled trial of short bursts of a potent topical corticosteroid versus prolonged use of a mild preparation for children with mild or moderate atopic eczema. British Medical Journal 324(7340), 768-771. [Abstract] [Free Full-text]

Uehara, M. and Kimura, C. (1993) Descendant family history of atopic dermatitis. Acta Dermato-Venereologica 73(1), 62-63. [Abstract]

UKTIS (2012a) Use of penicillins in pregnancy. TOXBASEUK Teratology Information Service. www.toxbase.org

UKTIS (2012b) Use of erythromycin in pregnancy. TOXBASEUK Teratology Information Service. www.toxbase.org

UKTIS (2012c) Use of clarithromycin in pregnancy. TOXBASEUK Teratology Information Service. www.toxbase.org

Wallace, D.V. and Dykeqicz, M.S. (2008) The diagnosis and management of rhinitis: an updated practice parameter. Journal of Allergic Clinical Immunology 122(2), S1-S84. [Free Full-text]

Williams, H.C. (2007) Established corticosteroid creams should be applied only once daily in patients with atopic eczema. British Medical Journal 334(7606), 1272. [Free Full-text]

Williams, H.C., Burney, P.G.J., Hay, R.J. et al. (1994) The U.K. Working Party's diagnostic criteria for atopic dermatitis. I: derivation of a minimum set of discriminators for atopic dermatitis. British Journal of Dermatology 131(3), 383-396. [Abstract]

Wüthrich, B. (1996) Epidemiology and natural history of atopic dermatitis. Allergy and Clinical Immunology International 8(3), 77-82.