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1 Treating atopic eczema in children aged 12 and under bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this pathway see: Pathway last updated: 17 May 2016 This document contains a single pathway diagram and uses numbering to link the boxes to the associated recommendations. All rights reserved

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3 1 Child with atopic eczema No additional information 2 Stepped approach to treatment Use a stepped approach for managing atopic eczema in children. This means 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, with the addition of the other treatments shown in the table below. Stepped care: treatment options Mild Moderate Severe Emollients Emollients Emollients Mild potency topical corticosteroids Moderate potency topical corticosteroids Potent topical corticosteroids Topical calcineurin inhibitors Topical calcineurin inhibitors Bandages and dressings Bandages and dressings Phototherapy Systemic therapy Be aware that areas of atopic eczema of differing severity can coexist in the same child. If this is the case, each area should be treated independently. Page 3 of 14

4 Treating eczema on the face and neck and on vulnerable sites For specific information on treating atopic eczema on the face and neck, and on vulnerable sites such as the axillae and groin, see topical corticosteroids [See page 6] and topical calcineurin inhibitors [See page 7] in this pathway. Flares Offer information on how to recognise flares (increased dryness, itching, redness, swelling and general irritability). Give clear instructions on how to manage flares according to the stepped-care plan and prescribe treatments that allow children and their parents or carers to follow this plan. Treatment for flares should be started as soon as signs and symptoms appear. Continue for approximately 48 hours after symptoms subside. Antihistamines Do not routinely use oral antihistamines in the management of atopic eczema in children. Offer a 1-month trial of a non-sedating antihistamine to: children with severe atopic eczema children with mild or moderate atopic eczema where there is severe itching or urticaria. If successful, treatment can be continued while symptoms persist. Review every 3 months. Offer a 7 14 day trial of an age-appropriate sedating antihistamine to children aged 6 months or over during acute flares if sleep disturbance has a significant impact on the child or parents or carers. This can be repeated during subsequent flares if successful. Quality standards The following quality statements are relevant to this part of the pathway. 2. Stepped approach to management 4. Provision of emollients Page 4 of 14

5 3 Emollients Offer a choice of unperfumed emollients: suited to the child's needs and preferences for everyday moisturising, washing and bathing. Emollients should be: used more often and in larger amounts than other treatments used on the whole body even when atopic eczema is clear used while using other treatments used instead of soaps and detergent-based wash products used instead of shampoos for children aged under 12 months (emollient wash products can also be used) offered as a single product for all purposes or a combination (offer alternatives if one emollient causes irritation or is not acceptable). For children aged over 12 months, use an unperfumed shampoo, ideally labelled as being suitable for eczema; washing the hair in bath water should be avoided. Prescribe leave-on emollients in large quantities ( g weekly). These should be easily available to use at nursery, pre-school or school. Show children and their parents or carers how to apply emollients, including how to smooth emollients onto the skin rather than rubbing them in. Where emollients (excluding bath emollients) and other topical products are used at the same time of day, the different products should ideally be applied one at a time with several minutes between applications where practical. The preferences of the child and parents or carers should determine which product should be applied first. Review repeat prescriptions of individual products and combinations of products with children and their parents or carers at least once a year to ensure that therapy remains optimal. Quality standards The following quality statements are relevant to this part of the pathway. 2. Stepped approach to management Page 5 of 14

6 4. Provision of emollients 4 Topical corticosteroids Information for children and their parents or carers Discuss the benefits and harms of treatment with topical corticosteroids and: emphasise that the benefits outweigh possible harms when applied correctly explain that topical corticosteroids should only be applied to areas of active atopic eczema (or eczema that has been active in the past 48 hours), which may include areas of broken skin. Tailoring treatment Tailor the potency of topical corticosteroids to the severity of the child's atopic eczema, which may vary according to body site. They should be used as follows: use mild potency for mild atopic eczema use moderate potency for moderate atopic eczema use 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 axillae and groin do not use very potent preparations without specialist dermatological advice. Exclude secondary bacterial or viral infection if a mild or moderately potent topical corticosteroid has not controlled the atopic eczema within 7 14 days. Then, in children aged 12 months or over, use potent topical corticosteroids for as short a time as possible and no longer than 14 days. If this treatment does not control the atopic eczema, review the diagnosis and refer for specialist dermatological advice. Do not use potent topical corticosteroids on the face and neck. Do not use potent topical corticosteroids in children under 12 months without specialist dermatological supervision. Consider treating problem areas of atopic eczema with topical corticosteroids for two consecutive days per week to prevent flares, instead of treating flares as they arise, in children Page 6 of 14

7 with frequent flares (two or three per month). Review this strategy within 3 6 months to assess effectiveness. Consider a different topical corticosteroid of the same potency as an alternative to stepping up treatment if you suspect tachyphylaxis. Frequency of application The following recommendations are from NICE technology appraisal guidance on frequency of application of topical corticosteroids for atopic eczema. It is recommended that topical corticosteroids for atopic eczema should be prescribed for application only once or twice daily. It is recommended 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 has written information for the public explaining its guidance on the frequency of application of topical corticosteroids for atopic eczema. Labelling Apply labels stating the potency class of topical corticosteroids to the container (for example, the tube), not the outer packaging. 5 Topical calcineurin inhibitors The following recommendations are from NICE technology appraisal guidance on tacrolimus and pimecrolimus for atopic eczema. Topical tacrolimus and pimecrolimus are not recommended for the treatment of mild atopic eczema or as first-line treatments for atopic eczema of any severity. Topical tacrolimus is recommended, within its licensed indications, as an option for the secondline 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, particularly irreversible skin atrophy. Page 7 of 14

8 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, particularly irreversible skin atrophy. For the purposes of this guidance, atopic eczema that has not been controlled by topical corticosteroids refers to disease that has not shown a satisfactory clinical response to adequate use of the maximum strength and potency that is appropriate for the patient's age and the area being treated. It is recommended that treatment with tacrolimus or pimecrolimus be initiated only by physicians (including general practitioners) with a special interest and experience in dermatology, and only after careful discussion with the patient about the potential risks and benefits of all appropriate second-line treatment options. NICE has written information for the public explaining its guidance on tacrolimus and pimecrolimus for atopic eczema. Topical calcineurin inhibitors for facial atopic eczema Consider stepping up treatment to topical calcineurin inhibitors for facial atopic eczema in children that requires long-term or frequent use of mild topical corticosteroids. Application Explain that topical calcineurin inhibitors should only be applied to areas of active atopic eczema, which may include areas of broken skin. Do not use topical calcineurin inhibitors under occlusion (bandages and dressings) for treating atopic eczema in children without specialist dermatological advice. 6 Bandages and dressings Localised medicated dressings or dry bandages can be used: with emollients for areas of chronic lichenified (localised skin thickening) atopic eczema with emollients and topical corticosteroids for short-term treatment of flares (7 14 days) or areas of chronic lichenified eczema. Page 8 of 14

9 Use whole-body (limbs and trunk) occlusive dressings (including wet wrap therapy) with topical corticosteroids for 7 14 days only (or for longer with specialist dermatological advice). Use can be continued with emollients alone until the atopic eczema is controlled. Do not use: occlusive medicated dressings or dry bandages to treat infected atopic eczema whole-body (limbs and trunk) occlusive dressings (including wet wrap therapy) or wholebody dry bandages (including tubular bandages and garments) as first-line treatment these should only be initiated by a healthcare professional trained in their use. 7 Phototherapy and systemic treatments Consider phototherapy or systemic treatments for severe atopic eczema when: other management options have failed or are inappropriate there is a significant negative impact on quality of life. Treatment should be undertaken only under specialist dermatological supervision by staff who are experienced in dealing with children. Only initiate phototherapy or systemic treatments in children with atopic eczema after assessment and documentation of severity of atopic eczema and quality of life. 8 Treating infections Inform children and their parents or carers that they should obtain new supplies of topical medications after treatment for infected atopic eczema because products in open containers can be contaminated with microorganisms and act as a source of infection. NICE has produced a pathway on antimicrobial stewardship. 9 Bacterial infection Offer information on 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) Page 9 of 14

10 access appropriate treatment when a child's atopic eczema becomes infected. Take swabs from infected lesions of atopic eczema only if you suspect microorganisms other than Staphylococcus aureus or if you think antibiotic resistance is relevant. Treatment Use for Time Systemic antibiotics active against S. aureus and streptococcus Widespread bacterial infections 1 2 weeks (according to clinical response) Topical antibiotics, including those combined with topical corticosteroids Clinical infection in localised areas Maximum of 2 weeks Flucloxacillin First-line treatment of S. aureus and streptococcal infections As indicated Erythromycin First-line treatment of S. aureus and streptococcal infections in the case of allergy to flucloxacillin or flucloxacillin resistance As indicated Clarithromycin First-line treatment of S. aureus and streptococcal infections in the case of allergy to flucloxacillin or flucloxacillin resistance and if erythromycin is not well tolerated As indicated Antiseptics such as triclosan or chlorhexidine Adjunct therapy (at appropriate dilutions) to decrease bacterial load in cases of recurrent infected atopic eczema Avoid longterm use Page 10 of 14

11 Quality standards The following quality statement is relevant to this part of the pathway. 2. Stepped approach to management 10 Herpes infection Consider infection with herpes simplex (cold sore) virus if a child's infected atopic eczema fails to respond to treatment with antibiotics and an appropriate topical corticosteroid. If a child with atopic eczema has a lesion on the skin suspected to be herpes simplex virus, start treatment with oral aciclovir even if the infection is localised. Treat suspected eczema herpeticum (widespread herpes simplex virus) immediately with systemic aciclovir and refer for same-day specialist dermatological advice. If you also suspect secondary bacterial infection, start treatment with appropriate systemic antibiotics as well. Treat eczema herpeticum that involves the skin round the eyes with systemic aciclovir and refer for same-day ophthalmological and dermatological advice. Offer information on how to recognise signs of eczema herpeticum: areas of rapidly worsening, painful eczema possible fever, lethargy or distress 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). Quality standards The following quality statements are relevant to this part of the pathway. 5. Referral for specialist dermatological advice 7. Treatment of eczema herpeticum Page 11 of 14

12 11 When to refer See eczema / eczema overview / When to refer 12 Complementary therapies Discuss complementary therapies with the child and their parents or carers and inform them that: the effectiveness and safety of complementary therapies such as homeopathy, herbal medicine, massage and food supplements for the management of atopic eczema have not been adequately assessed in clinical studies they should be cautious with the use of herbal medicines in children and be wary of any herbal product that is not labelled in English or does not come with information about safe usage (see herbal medicines: advice to consumers on the NHS Choices website) topical corticosteroids are deliberately added to some herbal products intended for use in children with atopic eczema (see herbal medicines: advice to consumers on the NHS Choices website) liver toxicity has been associated with the use of some Chinese herbal medicines intended to treat atopic eczema they should inform their healthcare professional if they are using or intend to use complementary therapies they should keep using emollients as well as any complementary therapies regular massage with emollients may improve the atopic eczema. Page 12 of 14

13 DLQI dermatology life quality index PGA physician's global assessment Sources Atopic eczema in under 12s: diagnosis and management (2007) NICE guideline CG57 Tacrolimus and pimecrolimus for atopic eczema (2004) NICE technology appraisal guidance 82 Frequency of application of topical corticosteroids for atopic eczema (2004) NICE technology appraisal guidance 81 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Page 13 of 14

14 Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT Page 14 of 14

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