Guidelines for outpatient treatment of childhood eczema

Read these guidelines in association with:

• Guidelines for the diagnosis and evaluation of eczema
• Guidelines for managing adult eczema

Most children with eczema can be managed in an outpatient setting.

Treatment should be prescribed as a package that includes:

• Tips on how to avoid triggers /irritants
• Tips on baths and soap substitutes
• Moisturizers (emollients)
• Current corticosteroids / calcineurin inhibitors
• Antibiotics and antihistamines if necessary.
• Tips on recognizing infection
• A clear plan for review by a healthcare professional.

Prescribers need to spend time to ensure that children and their caregivers understand all aspects of therapy and how to use them.

Recipes for topical treatments should be supported with verbal instructions, written information (eg, eczema action plan, brochures) and demonstration (eg, videos). Educating an eczema nurse has been shown to improve adherence and treatment effectiveness. [1]

Resources for families

1. kidshealth.org.nz: includes videos and brochures

Resources for prescribers include:

• NICE guidelines [2]
• SafeRx Eczema in children [3]
• Health Point Pathways [4]

Swimming pool

• Baths are recommended once or twice a day.
• It is recommended that the water be warm and that the baths last no more than 10 minutes.
• Emollient or emollient washing products should be used instead of soap and shampoo.
• Bath oils help hydrate the skin, but can make the bath slippery. A trial published in 2018 indicated that bath additives may be worthless.
• Regular antiseptic baths twice a week with dilute sodium hypochlorite (lye baths) or triclosan bath oils can reduce staphylococcal transport and improve eczema. [5]

Emollients / moisturizers

• Children should receive emollients to use every day to hydrate, wash and bathe. These should not be scented and, when possible, fully funded by prescription.
• Children should receive 250 to 500 g of emollient per week.
• Emollients should be applied several times a day to the entire body and continue even when the eczema is gone.
• Emollients should be smoothed (not rubbed) in the direction of hair increase. They can be allowed to soak up.
• When possible, the emollient should be provided in a container or pump tube. Emollients in open containers can become contaminated. The emollient should be decanted from the tubs with a clean spoon or spatula before each use. Bathtubs should be discarded after an episode of skin infection.
• If a child irritates or dislikes the child, then an alternative should be offered.
• Increased use of emollients has been associated with improved eczema and less need for topical corticosteroids.

Topical corticosteroids

The benefits and harms of topical corticosteroids should be discussed with the family / caregivers, emphasizing that the benefits outweigh the possible harms when used correctly.

The potency of topical corticosteroids must be adapted to the child's eczema:

Mild power

• For mild eczema
• For infants <12 meses
• For the face and neck

Moderate power

• For moderate eczema
• For short-term use of 5 to 7 days in armpits and groin and from severe facial outbreaks

Powerful

• For severe eczema
• Its use on the face and neck is not recommended.

Do not use super potent topical corticosteroids in children (or potent in children younger than 12 months) without specialized dermatological advice. [2]

• Topical corticosteroids should only be applied to areas of active eczema and stopped when the eczema is gone. Emollients should be continued.
• Topical corticosteroids should be applied to the affected area in a thin layer once or twice a day. They can be applied before or after emollients.
• Dilution of topical corticosteroids in emollients or other products has not been shown to reduce potency.
• Long-term continuous use of topical steroids can rarely cause side effects, for example, thinning of the skin and adrenal suppression with extended request. It is recommended that children using topical steroids be checked regularly and the frequency of treatment is decreased as much as possible. Children who require continued use of topical steroids should be checked by a dermatologist.
• Long-term maintenance use of topical steroids 2 days per week (“weekend treatment”) seems safe and effective. [6]

Topical calcineurin inhibitors.

• Topical calcineurin inhibitors (TCI) are a second-line therapy for eczema that has not responded to appropriate topical corticosteroids. TCIs can be considered when there is a risk of side effects from topical corticosteroids.
• The risks and benefits of TCIs should be discussed with the patient and caregivers, and other treatment options should be discussed. It is recommended that they not be used without specialized dermatological advice. [two]
• Topical pimecrolimus is approved for the use of eczema on the face and neck in children older than 2 years.
• Topical tacrolimus is not registered in New Zealand.

Antihistamines

• Antihistamines are not recommended for routine use.
• It can be considered a short test (<1 mes) de un antihistamínico no sedante para el eccema moderado-severo o cuando se asocia urticaria. The benefit of continued use should be reviewed every 3 months.
• Sedative antihistamines can be used to help sleep during acute flares in children older than 6 months. [2]

Antibiotics

• Topical antibiotics can be used to located (<5 cm) áreas de infección de la piel por hasta 7 días.
• Systemic Antibiotics should be prescribed for 7 to 14 days to treat generalized infection.
• The choice of antibiotics will depend on local patterns of antibiotic resistance, but must be active against Staphylococcus aureus and streptococci. [4]

Reassess

If there is no improvement after 7 to 14 days of treatment, the following should be considered:

• Incomplete adherence to prescribed treatments.
• Continuous exposure to irritants, for example, sodium lauryl sulfate, soap.
• Inadequate amount or potency of topical corticosteroids applied
• Secondary skin infection
• Contact allergy for example, to prescription products or aeroallergens
• Incorrect diagnosis

When to refer