Atopic eczema is a chronic, relapsing, inflammatory skin condition characterised by an itchy red rash that favours the skin creases such as the folds of the elbows or behind the knees.
- Atopic eczema is common and the prevalence is increasing. It is seen in 20% of children in developed countries and in developing countries the prevalence is heading towards this figure.In adults, population studies report an overall prevalence of 2-18%.
- The large majority (about 80%) of cases present before the age of 5 years.
- There is an increased prevalence in those with an affected parent.
Environmental irritants and allergens
- Irritants - eg, soaps and detergents (including shampoos, bubble baths, shower gels and washing-up liquids).
- Skin infections: Staphylococcus aureus is believed to be an important exacerbating factor in atopic eczema.
- Contact allergens.
- Extremes of temperature and humidity. Most patients improve in summer and are worse in winter. Sweating induced by heat or exercise can provoke an exacerbation.
- Abrasive fabrics - eg, wool.
- Dietary factors aggravate atopic eczema in about 50% of children but much less frequently in adults.Food allergy should be suspected 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, particularly if associated with gut dysmotility (colic, vomiting, altered bowel habit) or failure to thrive.
- Inhaled allergens - eg, house dust mites, pollens, pet dander and moulds. Inhaled allergy should be suspected in children with seasonal flares of atopic eczema, associated asthma and rhinitis, or children aged over 3 years with atopic eczema on the face.
- It is thought that genetic mutations affect the production of filaggrin. Filaggrin is a protein critical to the conversion of keratinocytes to the protein/lipid squames that compose the stratum corneum, the outermost barrier layer of the skin. Therefore, in at least some patients with atopic eczema, there is a genetic predisposition that increases their sensitivity to external environmental triggers.
- Stress may exacerbate atopic eczema, which itself may be a cause of psychological distress.
- Hormonal changes in women - eg, premenstrual flare-ups, deterioration in pregnancy.
- Must have an itchy skin condition (or report of scratching or rubbing in a child) plus three or more of the following:
- History of itchiness in skin creases such as folds of the elbows, behind the knees, fronts of ankles, or around the neck (or the cheeks in children aged 18 months or under).
- History of asthma or hay fever (or history of atopic disease in a first-degree relative in children aged under 4 years).
- General dry skin in the preceding year.
- Visible flexural eczema (or eczema affecting the cheeks or forehead and outer limbs in children aged under 4 years).
- Onset in the first two years of life (not always diagnostic in children aged under 4 years).
- If it does not itch it is very unlikely to be eczema.
- The distribution tends to vary with age and the appearance of persistent lesions may alter with scratching.
- A tendency to dry skin persists throughout life.
- Acute flare-ups vary in appearance from vesicles to areas of poorly demarcated redness. Other possible features include crusting, scaling, cracking and swelling of the skin.
- Repeated scratching often leads to thickening of chronic lesions.
- During infancy, atopic eczema primarily involves the face, the scalp and the extensor surfaces of the limbs. It is usually acute. The nappy area is usually spared.
- In children and in adults with long-standing disease, eczema is often localised to the flexure of the limbs.
- Adults: often generalised dryness and itching.
- Chronic eczema on the hand may be the primary manifestation.
- Bacterial infection is suggested by:
- Crusting, weeping, pustulation and/or surrounding cellulitis with erythema of otherwise normal-looking skin.
- A sudden worsening of the condition.
- Eczema herpeticum is suggested by:
- 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 (may coalesce to form larger areas of erosion with crusting).
- Possible fever, lethargy or distress.
Assessment of severity and well-being in a child with atopic eczema
In assessment of severity, psychological and psychosocial well-being and quality of life, take into account the impact of atopic eczema on parents or carers, as well as the child and provide appropriate advice and support. The following assessment tools can be used (see links under 'Further reading & references', below):
- Visual analogue scales (0-10) capturing the child/parent/carer's assessment of severity, itch and sleep loss over the previous three days and nights.
- Patient-oriented Eczema Measure (POEM).
- Children's Dermatology Life Quality Index (CDLQI).
- Infants' Dermatitis Quality of Life Index (IDQOL).
- Dermatitis Family Impact (DFI) Questionnaire.
- Contact dermatitis.
- Seborrhoeic dermatitis.
- Fungal infections.
- Lichen simplex chronicus.
- Scabies and other infestations.
- Investigations are rarely required to establish the diagnosis.
- Most children with mild atopic eczema do not need clinical testing for allergies.
- There is no evidence of the value of high-street or internet allergy tests in the management of atopic eczema.
- Estimation of immunoglobulin E (IgE) and specific radioallergosorbant tests (RASTs) only confirm the atopic nature of the individual.
- Swabs for bacteriology are particularly useful if patients do not respond to treatment, in order to identify antibiotic-resistant strains of S. aureus or to detect additional streptococcal infection.
- Provide information about the condition, the factors that may provoke it, the role of different treatments and their effective and safe use. It is important to emphasise the correct quantities of topical treatments to use. Use written information to reinforce information discussed.
- Include information on how to recognise flares of atopic eczema (increased dryness, itching, redness, swelling and general irritability).
- Information should also include how to recognise the symptoms and signs of bacterial infection with staphylococcus and/or streptococcus (weeping, pustules, crusts, atopic eczema failing to respond to therapy, rapidly worsening atopic eczema, fever and malaise).
- Provide support: living with skin disease, especially the potential psychosocial difficulties, can be very difficult.
- Provoking factors should be identified and avoided when practical. Avoid anything that is known to increase disease severity: advise avoidance of extremes in temperature and humidity, avoid irritating clothes containing wool or certain synthetic fibres (use non-abrasive clothing fabrics, such as cotton).
- Advise keeping nails short and avoid use of soaps or detergents; replace with emollient substitutes (use gloves when unable to avoid handling irritants such as detergents).
- Keep the skin hydrated: use of baths and bath additives and reduction of water loss by the use of sufficient appropriate emollient therapy, used liberally.
- A stepped approach should be used for managing atopic eczema in children, ie tailoring the treatment step to the severity of the atopic eczema. Management can then be stepped up or down, according to the severity of symptoms.
- Emollients should form the basis of atopic eczema management and should always be used, even when the atopic eczema is clear.
- These are best applied when the skin is moist but they should also be applied at other times.
- They should be applied as liberally and frequently as possible and continual treatment with complete emollient therapy (combinations of cream, ointment, bath oil and emollient soap substitute) will help to provide maximal effect.
- Ideally the frequency of application of emollients should be every 4 hours or at least 3-4 times per day.
- They should be prescribed in large quantities, with the recommended quantities used in generalised eczema being 500 g/week for an adult and 250 g/week for a child.
- Intensive use of emollients will reduce the need for topical steroids.
- Education on how to use emollients is essential to ensure maximal rehydration of the skin.
- Mild corticosteroids are generally used on the face and on flexures; potent corticosteroids are generally required for use on adults with discoid or lichenified eczema or with eczema on the scalp, limbs and trunk.
- It is recommended that topical corticosteroids for atopic eczema should be prescribed for application only once or twice daily.
- Use mild potency for mild atopic eczema, moderate potency for moderate atopic eczema and potent for severe atopic eczema.
- Use mild potency for the face and neck, except for short-term (3-5 days) use of moderate potency for severe flares.
- Use moderate or potent preparations for short periods only (7-14 days) for flares in vulnerable sites such as the axillae and groin.
- Do not use very potent preparations in children, without specialist dermatological advice.
- Patients using moderate and potent steroids must be kept under review for both local and systemic side-effects.
- Chronic eczema in adults: this often requires a potent steroid together with emollients and allergen avoidance.
- Emollient antimicrobial preparations can help prevent infection.
- Oral antibiotics are often necessary in moderate-to-severe infection; a 14-day course should be given.
- Oral flucloxacillin is usually most appropriate for treating S. aureus and erythromycin used if there is penicillin allergy or penicillin resistance.
- Penicillin should be given if beta-haemolytic streptococci are isolated.
- Steroid-antibiotic combinations are effective in clinical practice although there is no evidence for greater efficacy.
- Results from repeated scratching.
- Initially treated with a potent corticosteroid.
- Bandages containing ichthammol paste (to reduce pruritus) and other substances such as zinc oxide may be applied over the corticosteroid.
- Coal tar and ichthammol can be useful in some cases of chronic eczema.
- Initially, this requires a potent corticosteroid.
- Infection may also be present and requires treatment.
- Potassium permanganate solution (1 in 10,000) can be used in exudative eczema, for its antiseptic and astringent effect.
Severe refractory eczema
- This requires management under specialist supervision.
- It may require phototherapy, systemic corticosteroids or other drugs acting on the immune system - eg, ciclosporin, azathioprine, mycophenolate mofetil.
- Alitretinoin is recommended as a treatment option for adults with severe chronic hand eczema that has not responded to potent topical corticosteroids, if the person has severe disease and a Dermatology Life Quality Index (DLQI) score of 15 or more.
- Hydrolysed formulas should not be offered to infants in preference to breast milk for
- the prevention of atopic eczema..
- Do not use diets based on unmodified proteins of other species' milk (for example, goat's or sheep's milk) or partially hydrolysed formulas for the treatment of suspected cow's milk allergy. Diets including soya protein can be offered to children aged over 6 months with specialist dietary advice.
- Refer for specialist dietary advice children who follow a cow's milk-free diet for more than eight weeks.
- It is not known whether altering a breast-feeding mother's diet is effective in reducing the severity of the condition. A trial of an allergen-specific exclusion diet under dietary supervision may be considered.
- Parents should be advised that where there is a family history of atopy, exclusive breast-feeding for the first 3 months reduces the risk of infantile eczema.
- There is little evidence to support the use of various exclusion diets in unselected people with atopic eczema.However, if food allergy is diagnosed by using thorough diagnostic procedures such as oral food allergy challenges, exclusion of specific trigger foods can make a significant clinical difference.
- Settle inflammation with topical corticosteroids.
- Treat clinically apparent bacterial infection with oral antibiotics; moderate and severe infection requires a 14-day course of flucloxacillin (or erythromycin if the patient has a penicillin allergy).
- Urgently refer or admit someone with severe unresponsive disease. Admit anyone with suspected infection with herpes simplex virus (eczema herpeticum).
Managing frequent flare-ups
- Change the emollient to one with a higher lipid content.
- Advise the person to apply the emollient more often.
- Recommend applying more emollient each time.
- Review the factors that might be provoking flare-ups; avoid environmental irritants and stresses where possible.
Tacrolimus and pimecrolimus for atopic eczema
- The National Institute for Health and Care Excellence (NICE) has recommended that topical pimecrolimus and tacrolimus are options for atopic eczema not controlled by maximal topical corticosteroid treatment or if there is a risk of important corticosteroid side-effects (particularly skin atrophy).
- Topical pimecrolimus is recommended for moderate atopic eczema on the face and neck of children aged 2-16 years.
- However, a Cochrane review concluded that topical pimecrolimus is less effective than moderate and potent corticosteroids and 0.1% tacrolimus and that the therapeutic role of topical pimecrolimus is uncertain due to the absence of key comparisons with mild corticosteroids.
- Topical tacrolimus is recommended for moderate-to-severe atopic eczema in adults and children aged over 2 years.
Referral for specialist dermatological advice is recommended for children with atopic eczema if:
- The diagnosis is, or has become, uncertain.
- Management has not controlled the atopic eczema satisfactorily based on a subjective assessment by the child, parent or carer (eg, the child is having 1-2 weeks of flares per month or is reacting adversely to many emollients).
- Atopic eczema on the face has not responded to appropriate treatment.
- The child or parent/carer may benefit from specialist advice on treatment application (eg, bandaging techniques).
- Contact allergic dermatitis is suspected (for example, persistent atopic eczema or facial, eyelid or hand atopic eczema).
- The atopic eczema is giving rise to significant social or psychological problems for the child or parent/carer (for example, sleep disturbance, poor school attendance).
- Atopic eczema is associated with severe and recurrent infections, especially deep abscesses or pneumonia.
Treatments provided in secondary care
- Bandaging (eg, use of wet wraps).
- Initiation of a topical calcineurin inhibitor (tacrolimus or pimecrolimus).
- Initiation and monitoring of a systemic immunosuppressant - eg, ciclosporin or azathioprine.
- Use of very potent topical corticosteroids (for areas of chronic recalcitrant eczema).
- A short period of hospitalisation to remove the person from environmental antigens or emotional stresses, provide intense education and assure compliance with treatment.
- S. aureus infection may present with typical impetigo or as worsening of the eczema with increased redness, oozing and crusting.
- Herpes simplex infection, indicated by grouped vesicles and punched-out erosions, can also occur. Disseminated herpes simplex viral infection, eczema herpeticum, presents with widespread lesions that may coalesce to large, denuded, bleeding areas that can extend over the entire body.
- Superficial fungal infections are also more common in people with atopic eczema.
- Disturbed sleep patterns.
- Reduced self-esteem because of chronic visible disease.
- Isolation from other children - eg, when they are unable to swim.
- Adverse effects on a child's behaviour and development: poor sleep, reduced self-esteem and social isolation.
- Usually a relapsing course, with a tendency to gradual improvement in adult life.
- Atopic eczema can be expected to clear in 60-70% of children by their early teens, although relapses may occur.
- Predictors of a worse prognosis include early onset of disease and in children with associated asthma
Further reading and references
Patient-Oriented Eczema Measure (POEM); University of Nottingham
Children's Dermatology Life Quality Index (CDLQI); Cardiff University
Infants' Dermatitis Quality of Life Index (IDQOL); Cardiff University
Dermatitis Family Impact (DFI) Questionnaire; Cardiff University
Bantz SK, Zhu Z, Zheng T; The Atopic March: Progression from Atopic Dermatitis to Allergic Rhinitis and Asthma. J Clin Cell Immunol. 2014 Apr5(2). pii: 202.
Deckers IA, McLean S, Linssen S, et al; Investigating international time trends in the incidence and prevalence of atopic eczema 1990-2010: a systematic review of epidemiological studies. PLoS One. 20127(7):e39803. doi: 10.1371/journal.pone.0039803. Epub 2012 Jul 11.
Flohr C, Mann J; New insights into the epidemiology of childhood atopic dermatitis. Allergy. 2014 Jan69(1):3-16. doi: 10.1111/all.12270. Epub 2013 Nov 21.
Harrop J, Chinn S, Verlato G, et al; Eczema, atopy and allergen exposure in adults: a population-based study. Clin Exp Allergy. 2007 Apr37(4):526-35.
Thomsen SF; Atopic dermatitis: natural history, diagnosis, and treatment. ISRN Allergy. 2014 Apr 22014:354250. doi: 10.1155/2014/354250. eCollection 2014.
Atopic eczema in children; NICE Clinical Guideline (December 2007)
Farajzadeh S, Esfandiarpour I, Sedaghatmanesh M, et al; Epidemiology and clinical features of atopic dermatitis in kerman, a desert area of iran. Ann Dermatol. 2014 Feb26(1):26-34. doi: 10.5021/ad.2014.26.1.26. Epub 2014 Feb 17.
Werfel T, Ballmer-Weber B, Eigenmann PA, et al; Eczematous reactions to food in atopic eczema: position paper of the EAACI and GA2LEN. Allergy. 2007 Jul62(7):723-8.
Osawa R, Akiyama M, Shimizu H; Filaggrin gene defects and the risk of developing allergic disorders. Allergol Int. 2011 Mar60(1):1-9. doi: 10.2332/allergolint.10-RAI-0270. Epub 2011 Dec 25.
Eczema - atopic; NICE CKS, last revised March 2013 (UK access only)
Atopic eczema in children; NICE Quality Standard, Sept 2013
Frequency of application of topical corticosteroids for atopic eczema; NICE Technology Appraisal Guidance, August 2004
British National Formulary (BNF); NICE Evidence Services (UK access only)
Alitretinoin for the treatment of severe chronic hand eczema; NICE Technology Appraisal Guidance, August 2009
Management of atopic eczema in primary care; Scottish Intercollegiate Guidelines Network - SIGN (March 2011)
Bath-Hextall F, Delamere FM, Williams HC; Dietary exclusions for improving established atopic eczema in adults and children: systematic review. Allergy. 2009 Feb64(2):258-64. doi: 10.1111/j.1398-9995.2008.01917.x.
Eczema: Atopic Eczema; Primary Care Dermatology Society, 2015
Tacrolimus and pimecrolimus for atopic eczema; NICE Technology Appraisal Guidance, August 2004
Ashcroft DM, Chen LC, Garside R, et al; Topical pimecrolimus for eczema. Cochrane Database Syst Rev. 2007 Oct 17(4):CD005500.
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