Eczema

Introduction

Eczema (atopic dermatitis) is a very common skin condition that often begins in infancy or early childhood. Most affected children develop eczema before the age of two years, and it usually improves with age. There is often no single trigger for an eczema flare. Common causes of eczema flares in children include viral infections, overheating, sweat, direct contact with environmental irritants and change in environmental humidity.

Food allergy is more common in children with eczema who also have a family history of allergic disease. Managing eczema well in infants may reduce their chance of developing food allergy. Allergy testing is not routinely recommended for children with eczema and food elimination diets are also not routinely recommended. Skin prick testing and food challenges are usually only helpful in severe cases of eczema where there has been a poor response to first-line treatment or clinical history of allergic reaction.

Unless there is a known or suspected allergy, all infants including those with eczema, should be given a wide range of foods including smooth peanut paste, cooked egg, dairy and wheat products in their first year of life.

Pre-referral management

Please refer to Clinician Assist-Eczema in Children and the Perth Children's Hospital (PCH) Managing eczema in children: a guide for clinicians.

The following suggestions are not prescriptive but are a guide. GP review is advised after 2 weeks to assess response to treatment:

• If the eczema is not completely clearing with the prescribed topical corticosteroid at that time, consider whether infection may be present, differential diagnoses or whether a more potent topical corticosteroid is required. If a more potent topical corticosteroid is required, please prescribe accordingly and arrange further GP review in 4-6 weeks to assess response to treatment before referring to Dermatology.
• The majority of eczema referrals to the Dermatology department relate to suboptimal eczema treatment, either stopping topical corticosteroid too soon and not continuing use daily until the skin feels smooth and itch free or not being treated with an appropriate corticosteroid potency.

• Skin swabs for bacterial or viral infections if required.
• Swabs of potential staphylococcal aureus carriage sites should be considered in patients with recurrent episodes of infected eczema or skin infection. Suggested swab sites are nose, throat, axilla and wound. Refer to ChAMP Monographs and Guidelines for Staphylococcus aureus decolonisation-paediatric.

Common reasons for suboptimal management:

• Inadequate strength, amount and formulation of topical corticosteroid prescribed.
  • determined by child’s age, eczema severity and affected site(s).
• Advising corticosteroid use for a certain number of days rather than using daily until the eczema has completely cleared i.e. skin feels smooth and itch free.
• If treatment is ceased before the skin has returned to normal, it is more likely to flare again quickly.

When to refer

Up to 16 years of age; and has any of the following criteria, refer to Dermatology department:

• Moderate to severe eczema for ongoing management where topical corticosteroid is required on most days each week.
• Already on optimal treatment with a topical corticosteroid of moderate to high potency and not responding as expected. If using methylprednisolone aceponate 0.1% fatty ointment for example, please consider using mometasone furoate 0.1% ointment or betamethasone dipropionate 0.05% ointment as appropriate and arrange further GP review to assess response to treatment before referring to Dermatology. In the majority of cases, this will address the issue and prevent the need for referral.
• Persistent or frequent facial eczema requiring frequent use of topical corticosteroid.
• Recurrent episodes of infected eczema.
• Any patient with eczema or significant concern to the parent or GP that does not meet the above criteria.

Refer to Immunology Department if:

• There is a history of flare ups associated with food.
• If your concern relates to a suspected food allergy and/or environmental allergy.

How to refer

• Routine non-urgent referrals from a GP or a Consultant are made via the Central Referral Service.
• Routine non-urgent referrals from a nurse practitioner, non-medical referrers or private hospitals are made via the PCH Referral Office.
• Urgent referrals (less than seven days) are made via the PCH Referral Office. Please call PCH switchboard on (08) 6456 2222 to discuss with the Dermatology registrar. 

Essential information to include in your referral

• Severity and duration of eczema.
• Type of treatment used in the past and currently.
• If the patient has failed to respond to optimal first-line treatment.

References

1. Australian Medicines Handbook Children’s Dosing Companion Online [internet] Australia: Australian Medicines Handbook Pty. Ltd.; 2022.
2. Weston, Stephanie (Consultant Dermatologist), Expert Opinion, Perth Children’s Hospital, February 2022.

Useful resources

1. Eczema - PCH Emergency Department guidelines
2. Australian College of Dermatologists Consensus Statement Topical Corticosteroids in Paediatric Eczema
3. Clinician Assist WA » Eczema in Children
4. Staphylococcus aureus Decolonisation - ChAMP guideline
5. Staphylococcus aureus treatment - Health Fact sheet
6. Caring for your child's eczema - Health Fact sheet
   
   

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