• Introduction
• Aim
• Definition of Terms
• Assessment
• Management
• Management of complications - Infected eczema
• Documentation 
• Referrals 
• Follow up Recommendations
• Parent information
• Resources
• Evidence Table  
  

Introduction

Atopic eczema (AE) or atopic dermatitis (AD) is a chronic, inflammatory, skin condition that is itchy and often dry. It typically begins in early childhood and affects around 30% of children in Australia. 
This condition can worsen if not treated and cause intractable pruritus, soreness and sleep disturbance and can be complicated by secondary infection. The onset of eczema is commonly before 12 months of age and typically follows a remitting and relapsing course. Many children will "grow out of" eczema. There is no cure for AD, however if treated and managed effectively the disease has less impact on daily living and is less likely to have a negative effect on quality of life for the patient and family.

Aim

To provide evidence-based strategies for the management of AE in order to improve eczema severity and reduce the negative impact on patient and family quality of life. 

Definition of Terms

• Atopic eczema (AE): common, chronic inflammatory skin condition, presenting as generalised skin dryness and itch. Characterised by chronic dermatitis with remission and relapse with acute flares. Caused by interplay between environmental and genetic factors.
  
• Flares: a worsening of the eczema
  
• Triggers: factors that cause the eczema to flare 
  
• Wet dressings: dressings used in the treatment of eczema 
  
• Infected eczema: weeping and crusting occurs when the eczema is secondarily infected by organisms such as bacteria Staphylococcus aureus, Streptococci, Candida or viruses such as Herpes simplex and molluscum contagiosum 
  

Assessment

The UK Diagnostic Criteria for atopic eczema are:

• Must have itch
• Plus 3 or more of the following:
  • History of involvement in skin creases
  • Personal history of asthma or allergic rhinitis (or history of atopic disease in 1st degree relative if child is under 4 years of age)
  • A history of dry skin in the last year
  • Onset under the age of 2 years (not used if child is under 4 years)
  • Visible flexural eczema

Erythema: redness of the skin

Discoid eczema: disc shaped, clearly demarcated eczematous patches to limbs and trunk.

Assessment tools

Patient assessment should be undertaken by either a medical officer or an eczema nurse consultant/ practitioner to grade the degree of eczema severity (mild, moderate or severe), and the presence or absence of infection. Use  SCORAD (scoring atopic dermatitis) index calculator or EASI score to calculate the severity score.

Management

Eczema Treatments fall into two categories

1. Every day treatments and avoidance of triggers 

These treatments are ongoing regardless of the presence or absence of eczema.

• Avoiding environmental aggravators
  • Heat; such as thick layers of clothes, hot heaters, hot cars, classrooms, hot baths, thick blankets, woollen underlays or electric blankets and hot water bottles
  • Prickly/rough material for example wool, sandpits, clothing tags
  • Irritation; avoid products that contain plants, perfumes and foods
    
• Regular moisturiser, should be applied from top to toe at least twice a day even if the skin is clear of eczema to reduce the skin dryness. Creams should be removed from tubs onto clean paper and then taken from paper to skin to avoid bacterial contamination of the tub. 
  • When topical steroids are in use moisturisers should be applied directly over the steroids. 
    
  • Examples of over the counter in pharmacy moisturisers: QV creamtm, Cetaphil creamtm, Kenkay creamtm, Atoderm crèmetm, Avene xeracalmtm cream, Dermezetm treatment cream, CeraVetm Cream Lipikartm AP+M.
    
  • Creams should be removed from the tubs onto clean paper and then taken from the paper to the skin to avoid bacterial contamination of the tub. 
    
  • Avoid creams containing food, perfume or plant ingredients.
    
• Daily cool bath (30-32 degrees C); adding bath oil (1 capful). The face and head should also be wet well and the skin should not be rinsed with fresh water after the bath. It is no concern if the child swallows some of the water.
  
  • When the eczema is moderate to severe or the skin stings when the child bathes, salt (1/3 cup per 10 litres water) may be added.
    
  • When the eczema is infection or moderate to severe (or as recommended by healthcare professional) add household Bleach 4% (sodium hypochlorite 4%) (12mLs per 10 litres water). 
    
  • All three ingredients can be added together to the bath water. 
    
• Consider Vitamin D oral daily supplementation for moderate to severe eczema or if the baby is breast fed. This is especially important throughout Winter months.
  

2. Flaring treatments 

These treatments should be commenced as soon as there is a flare (when the skin is rough - like sandpaper, an increase in redness, itch and acute deterioration), and stopped when the symptoms are controlled and re-started if flaring again. As the eczema is better controlled the need for topical steroids will decrease however a moisturiser should always be applied at least twice daily.

Topical steroids and anti-inflammatory creams 

• For mild facial eczema use a weaker potency (than for body) steroid cream such as hydrocortisone 1% twice a day as required
  
• For moderate facial eczema which is non-responsive to steroids a pimecrolimus (Elideltm cream) can be used twice a day as required
  
• Use stronger steroid for the body (than for face) example Advantantm or Elocontm. These are available in cream, ointment, fatty ointment and lotion.
  

Tar creams are used when the skin is lichenified (thickening of the skin) or for discoid eczema. Tar creams should not be applied to the face, groin and flexures. These creams can be applied directly over the steroid creams and under the moisturiser. A suggested compound for a tar cream is 3% LPC in zinc cream (example KenKaytm dual purpose cream). 

Medications such as antibiotics or antivirals may be prescribed for treatment of organisms causing secondary infected eczema. Usually oral antibiotics are required however intravenous may be needed for severely infected eczema and sepsis.

If nasal swabs are positive for Staphylococcus aureus intranasal mupirocin ointment can be used twice daily for five days. If skin infections reoccur, consider treating the whole family using Staph decolonisation processes.

Antihistamines are not routinely used for eczema unless it has been triggered by an allergic reaction or insect bites. They do not assist with the eczema itch. Use with caution in children under 12 months of age.

Wet dressings are used for moderate to severe eczema or when the children are waking from the itch. The aim of wet dressing is to have greater penetration of topical moisturisers and to over hydrate the skin, also to sooth, cool and act as a barrier to scratching.

If the wet dressings (example Tubifasttm) are not readily available use wet clothes (onesie, leggings/T Shirt) instead. A dry layer of clothing may be applied over this however remove the top layer when dry and if awake. Wet dressings should only be needed for 3-5 nights. 

Wet dressings to re-hydrate and calm the skin using Tubifast ^tm

The Wet dressing/clothes regime is as follows:

• Mild eczema
  • Not required 
    
• Moderate eczema
  
  • Once to twice daily for 3 days
    
  • Nightly until the eczema is clear and then recommence nightly if flaring
    
• Severe eczema
  
  • Four times a day for 3 days only (Admission or HITH may be referred to assist during this acute phase)
    
  • Then taper to twice daily for one week
    
  • Then nightly until the eczema is clear and then recommence nightly if flaring.
    

Cool compressing for immediate relief of itch 

• Wet a cloth with water and plain bath oil (example chux or rediwipe)
  
• Apply to wet cloth to itchy areas for 5 -10 minutes, then apply a moisturiser post compressing
  
• These are also the wet dressing for the face, and are best applied while awake and when feeding
  
• Another option is using a thermal water spray to the itchy area
  
• Age dependant the children should be encouraged to learn this technique rather than scratching. 
  

Wet dressings

Cool compresses

Management of Complications - Infected eczema 

Secondary infection of eczema is a common complication as the skin is not intact and thus more vulnerable to infection. Infection can make eczema worse and more difficult to treat. A common causative bacterium is Staphylococcus aureus which is commonly found on eczema skin. 

Infection should be suspected if there is crusting, weeping, erythema, cracks, frank pus or multiple excoriations and increased soreness and itching which may suggest bacterial infection. 

Secondary viral infection caused by herpes simplex virus (HSV) is characterized by a sudden onset of grouped, small white or clear fluid filled vesicles, satellite or "punch out" lesions, pustules, and erosions. It is often tender, painful and itchy. Other viruses that may cause the eczema to flare are molluscum contagiosum and coxsackie A6 virus (hand foot and mouth disease).

Secondary bacterial infection

Secondary herpes simplex 1 infection

The principles of managing infected eczema are:

• Remove the crusts with a wet disposable cloth (example chux or rediwipe) and gently wipe. This is best done when bathing. 
  
• Steroid cream can be applied over open skin and presence of infection, however FIRST remove the crusts and weeping.
  

NOTE: most patients with viral infected eczema, invariably also have a bacterial skin infection as well. Assess using appropriate skin swabs to identify causative organism. 

Urgent Ophthalmology review if the infection is near the eye(s).

• To the daily bath add 
  
  • household bleach (4%) to the cool bath water (30 – 32 degrees). The dilution should be 12 mLs per 10 Litres of water. 
    
  • salt can be added to decrease stinging and to help settle inflammation and itch. The dilution is 100 grams per 10 Litres of water.
    
• For bacterial infections
  
  • Swabs can be taken if the treating doctor/nurse practitioner is unsure of the organism causing the infection or suspecting a multi resistant organism
    
  • Prescription of 
    
    • Oral antibiotics (example cephalexin or flucloxacillin) for 7 to 10 days
      
    • For children that are more unwell, febrile, sepsis due to the skin infection consider the need for IV antibiotics 
      
• For viral infections likely caused by HSV 
  • Prescription of 
    • oral aciclovir as soon as possible and within 48 hours of onset of symptoms. Little benefit will be realised if treatment is delayed beyond onset of symptoms after 72 hours (unless patient is immunocompromised or has progressive clinical state
    • IV aciclovir may be used for severe infections, those who are systemically unwell and febrile patients and those patients with threatened eye involvement 
      

Possible investigations

For every inpatient admitted for eczema bacterial skin swabs should be taken. 

• This swab should be collected from an open, excoriated, or crusted eczema lesion 
  
• Allowing determination of causative organism, and to identify organism resistances to assist with antimicrobial prescribing.
  

For patients attending the RCH Outpatient Department, a skin swab should be taken from an infected eczema lesion when MRSA is suspected or to verify a bacterial organism

Patient and parent nasal swabs are only required for patients who are experiencing recurrent infections and boils when suspecting ongoing nasal carriage.

Viral swabs may be needed to confirm causative organism, this should be collected from the base of a fresh blister.  

• Refer to RCH policies and procedure: specimen collection

Allergy:

In the event of an immediate reaction (such as urticaria and angioedema) to a food and/or severe persistent eczema in a baby, refer for specialist allergy evaluation. 

Visit ASCIA for more information:  https://www.allergy.org.au/images/pcc/ff/ASCIA_FAST_FACTS_Eczema_and_Food_Allergy_2020.pdf 

Refer to immunologist, allergist or dermatologist for Skin Prick Test (SPT) and a dietician if food allergies are proven on SPT or ImmunoCAP IgE test.

Documentation - Eczema Treatment Plan

All patients should have an Eczema Treatment Plan completed before they go home. To complete an Eczema Treatment Plan.

Referrals

A medical referral is required for

Follow up appointment recommendations

For further assistance the Dermatology Registrars can be paged via switchboard 9345 5522.

Parent education information

 Discuss the everyday treatments – avoidance of environmental triggers - overheating, rough prickly materials, and ensure regular and ongoing use of moisturisers and eczema baths.

Give guidance on eczema treatment plan 

• Give guidance that daily baths help to clean and remove the bacterial load from the skin, add moisture and decrease inflammation and itch.  
  
• Discuss the eczema treatment plan changes when flaring, commence flaring treatments as as soon as the flare begins and cease these treatments when symptoms decrease. Bleach can be added to baths for moderate, severe and infected eczema. Wet dressings/clothes  may assist in controlling a flare and promote sleep and can be applied if the other treatments have not cleared the eczema within 24 hours.
  

Encourage the families to undertake the Eczema E learn for education and demonstration of how to apply the topical treatments. 

Provide adequate prescriptions of topical steroid to cover until the patient is seen by the next professional such as GP, dermatologist, dermatology nurse consultant/practitioner. 

See  parent resources below

Eczema resources

For clinical staff:

• Eczema Treatment Plan
• SCORAD course and calculator
• Eczema Clinical Pathway
• Paediatric Eczema Nurse Practitioner Clinical Practice Guidelines
• ASCIA Fast facts Eczema and food allergy 2020

For parents:

• Eczema fact sheet
  
• RCH Dermatology website
  
• Knowing your child's eczema booklet
  
• Knowing your child's eczema booklet (Mandarin)
• Knowing your child's eczema booklet (Vietnamese)
  
• Nappy Rash information sheet
  
• Nappy Rash information sheet (Mandarin)
  
• Nappy Rash information sheet (Vietnamese)
  
• Eczema Bath information sheet new link 
  
• Eczema Bath information sheet (Mandarin) new link 
  
• Eczema Bath information sheet (Vietnamese) new link 
  
• Wet Dressing poster new link 
  
• Equipment Distribution Centre, For non-prescription treatment purchases at a reduced cost.
  
• The Eczema Association of Australasia   
  

Evidence table

Eczema Management Evidence Table

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Emma King, Nurse Practitioner and members of Dermatology Department and Allergy Department, and approved by the Nursing Clinical Effectiveness Committee. Updated June 2021.