Eczema (also known as atopic eczema, childhood eczema and atopic dermatitis) is a common dry, itchy skin condition that usually develops in early childhood, affecting 15–30% of children (Thandi et al, 2021). Around 70–90% of cases occur before 5 years of age, with a high incidence of onset in the first year of life, which may improve or resolve by late childhood (National Institute for Health and Care Excellence (NICE), 2023), although it may persist in adolescence and adulthood (Margolis et al, 2014). There are considerable differences in eczema incidence and prevalence by ethnicity, socio-demographic characteristics and geography, demonstrating the need to consider these factors when assessing health needs (De Lusignan et al, 2021).
Effective treatment of eczema demands good self-management which, if established early on, can lead to considerable improvements in quality of life (Ridd et al, 2017). Self-management can be particularly challenging during adolescence and early adulthood, and young people must take on a more active role in their eczema management, a role that was previously the primary responsibility of their families (Greenwell et al, 2021). The right education, guidance, support and self-management tools are crucial.
Without them, families and young people fail to keep their or their child's eczema under control, and there is poor adherence and treatment failure which has been observed by the family support team over several years. This, in turn, triggers avoidable repeat NHS appointments and worse health outcomes for the child or young person.
Improving the self-management skills of families, children and young people with eczema through the development of a personalised eczema treatment plan based on the clinical history and assessment will provide the foundations for this article, with links to national guidance and resources relating to ‘Two Treatments Used Well’ moisturising creams (emollients) and flare control creams (topical steroids) (Figure 1).
Eczema diagnosis and severity should be based on a detailed history, the clinical presentation and diagnostic criteria (Box 1). The history should include the use of validated tools to assess severity such as the Patient Oriented Eczema Measure (POEM) and RECAP (my Eczema Tracker) tools, visual analogue scales and age-specific dermatology quality-of-life tools (see Resources).
Box 1.Diagnostic criteria (NICE, 2023)Atopic eczema should be diagnosed when a child has an itchy skin condition, plus three or more of the following:
- Visible flexural dermatitis involving the skin creases, such as the bends of the elbows or behind the knees (or visible dermatitis on the cheeks and/or extensor areas in children aged 18 months or under)
- Personal history of flexural dermatitis (or dermatitis on the cheeks and/or extensor areas in children aged 18 months or under)
- Personal history of dry skin in the last 12 months
- Personal history of asthma or allergic rhinitis (or history of atopic disease in a first-degree relative of children aged under 4 years)
- Onset of signs and symptoms under the age of 2 years (this criterion should not be used in children aged under 4 years).
Health professionals should be aware that in Asian, black Caribbean and black African children, atopic eczema can affect the extensor surfaces rather than the flexures, and discoid (circular) or follicular (around hair follicles) patterns may be more common.
These assess the psychological impact of eczema and capture the child's and parents'/carers' assessment of severity, itch and sleep loss, and monitor the severity of the eczema, quality of life and response to treatment, as highlighted in the Quality Standards for Eczema (Box 2) (NICE, 2013; 2023). They have been incorporated into the care plan to be completed by parents, children and young people before their eczema consultation (https://eos.org.uk/healthcare-plans) (Figure 2).
Box 2.Quality Statements (NICE, 2013)Statement 1Children with atopic eczema are offered, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.Statement 2Children with atopic eczema are offered treatment based on recorded eczema severity using the stepped-care plan, supported by educationStatement 3Children with atopic eczema have their (and their families') psychological wellbeing and quality of life discussed and recorded at each eczema consultationStatement 4Children with atopic eczema are prescribed sufficient quantities (250–500 g weekly) from a choice of unperfumed emollients for daily use.Statement 5Children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema are referred for specialist dermatological advice.Statement 6Infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment are referred for specialist investigation to identify possible food and other allergens.Statement 7Children with atopic eczema who have suspected eczema herpeticum receive immediate treatment with systemic aciclovir and are referred for same-day specialist dermatological advice.
Detailed history and assessment
The following information forms the basis of the history taking (see eczema record sheet in Resources) and assessment before the physical examination, treatment and management plan (Lawton, 2022).
PMH and demographics
- Who normally lives with the child, is there shared care?
- Other illnesses and other atopic conditions, such as asthma and hay fever.
- Contact with any pets at home?
- Nursery, school and work experience/work and the impact eczema has, if any?
Growth and development
- Manipulation of diet and severe eczema may impact on the child's growth and development.
- Limited diets/iron deficiency may result in further itching. Identify what foods are being avoided.
- Eczema onset and duration
- At what age did they develop eczema and how long has it been present?
- What body sites are affected and what are the worst areas?
Family atopic history
- Is there, or has there been, anyone else in the family (first degree relative) with eczema, asthma or hay fever (allergic rhinitis) or other skin conditions? As per diagnostic criteria (Box 1).
- Are there any concerns regarding allergies and allergy testing for their child?
- Are there any suspected or confirmed allergies:
- To medicines or products that come into contact with or are applied to the skin
- To foods and environmental allergens – animals, grass, etc.
- What type of reactions occur, and have any tests been undertaken to confirm the allergies, and by whom?
- Have they noticed anything make the eczema flare? These can be irritant or allergic.
- There are often numerous triggers, which can cause flares of eczema and not one single cause (often asked about). They include:
- Foods, grass, pollen, animals
- Washing, body products, wipes
- Heat or sun, time of year with seasonal variations.
- Occupation, hobbies, and leisure time activities.
- Clothing, jewellery.
- Stress, illnesses.
- What everyday products (e.g. shampoo, soaps, wipes, make-up, perfumes, aftershave, etc.) do they use?
- What skincare products have they used in the past and what are they currently using?
- What medicines do they take regularly, including topical and systemic medications?
- What treatments have they used in the past and what are they currently using, including prescribed, over-the-counter? Natural or herbal products purchased from the internet or market stalls should raise suspicion if they provide a miraculous result, as many have been found to contain topical corticosteroids. These should be reported to the Medicines and Healthcare products Regulatory Agency (MHRA) (2014).
- How do they use their treatments? Which areas of the body do they apply the treatments? How often to the child's eczema? These issues will also be identified with the severity tools.
What are you hoping to gain from today's consultation? It is important to listen to the concerns of parents, children and young people, and their fears and expectations of treatment. In the world of social media, there are many sources of good and conflicting information regarding eczema, and consultations often involve unpicking and addressing these concerns and anxieties about eczema, allergy testing, safety of products and alternative therapies (Lawton et al, 2022). Many people expect a cure for eczema and hope an allergy test will find the cause for a dietary trigger. Consequently, they often find the concept of ‘control not cure’, or lack of routine allergy testing in eczema, hard to accept (Santer et al, 2012).
A fundamental aspect of caring for children, young people and their families is to provide optimum care based on the history, assessment and clinical presentation, while addressing their concerns and providing an evidence-based care plan that is realistic and achievable, and supports self-management.
‘Two Treatments Used Well’ provides the foundations of eczema treatment: the regular use of emollients (keep control creams) (Figure 1) to retain the skin's barrier function and treating flare-ups using topical corticosteroids (TCS; flare control creams). These should be tailored to the severity of the eczema and quality of life, including everyday activities and sleep, and psychosocial wellbeing, using a stepped approach (Box 3) (NICE, 2023). Eczema Care Online interventions to support self-management of eczema for parents/carers of children with eczema and young people who are starting to care for their eczema themselves provide clear guidance for using these two treatments well (Santer et al, 2022).
Box 3.Stepped treatment options based on severity (NICE, 2023)Clear: normal skin, no evidence of active atopic eczemaNone: no impact on quality of lifeMild atopic eczemaSkin and physical severity: areas of dry skin, infrequent itching (with or without small areas of redness)Impact on quality of life and psychosocial wellbeing: little impact on everyday activities, sleep and psychosocial wellbeingEmollientsMild potency topical corticosteroidsModerate atopic eczemaSkin and physical severity: areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening)Impact on quality of life and psychosocial wellbeing: moderate impact on everyday activities and psychosocial wellbeing, frequently disturbed sleepEmollientsModerate potency topical corticosteroidsTopical calcineurin inhibitorsBandages (initiated by a specialist)Severe atopic eczemaSkin and physical severity: widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation)Impact on quality of life and psychosocial wellbeing: severe limitation of everyday activities and psychosocial functioning, nightly loss of sleepEmollients Potent topical corticosteroids Topical calcineurin inhibitorsBandages Phototherapy Systemic therapy
More recently, concerns about topical steroids and topical steroid withdrawal have been raised in clinical practice and on social media, affecting adherence in some cases. This has been addressed with a joint statement from the British Association of Dermatologists and National Eczema Society (BAD and NES, 2021), reviewed by the MHRA. It concluded that they were unable to estimate the frequency of reactions and, given the large number of patients who use topical corticosteroids, reports of severe withdrawal reactions were very infrequent (MHRA, 2021). However, there is ongoing work and research relating to topical steroid withdrawal under way (NIHR School for Primary Care Research, 2023).
Information resources and treatment plans
Eczema Care Online (www.eczemacareonline.org.uk) is not only of benefit to children, young people and their families to support self-management, but is also a resource for clinical staff as it provides a useful, sustained benefit in reducing eczema severity in both children and young people when offered in addition to usual care. Its use is supported by experts in the field and eczema charities, including Eczema Outreach Support (Lawton et al, 2022). In addition, it is important to signpost to other reliable resources (see Resources) and to provide written treatment care plans.
For the majority of children, young people and their families, care is managed at home and they often find treatment regimens difficult to follow. Reasons include the use of multiple treatments for different parts of the body and different stages of severity (e.g. maintenance, flare-up); families lacking an understanding of how and why to use treatments; not being shown how to use them; or having a choice of emollient and it being difficult to fit the treatment plan around their lives. Thus, treatment adherence can be low, which can lead increased to increased flare-ups and repeated GP appointments, leading to families feeling overwhelmed and unable to manage eczema sufficiently (Powell et al, 2018).
One way to improve a family's confidence and make them feel better able to manage their child's eczema is to use a self-management care plan (Waldecker and King, 2017). Care plans provide written, personalised guidance on a treatment plan and are completed collaboratively with health professionals, children, young people and family, which provides the opportunity to clarify treatment and ensure that the regimen is feasible (Waldecker and King, 2017).
Eczema Outreach Support care plans for children and young people
The evidence-informed eczema care plans for children and young people were developed by Eczema Outreach Support and Dr Ella Guest from the Centre for Appearance Research, based at the University of the West of England. A mapping exercise was used to identify features of existing care plans, an online consensus exercise with health professionals (e.g. dermatologists, GPs, nurses, pharmacists and psychologists), young adults with eczema, and parents of children with eczema, to identify the most important content and design elements of a care plan.
Following this, draft iterations of the care plans were evaluated using a ‘think aloud’ technique, where young people with eczema and parents gave feedback on the care plans. The care plans include space for information about personalised step-wise treatment, what to do when eczema is in different stages of severity, and an assessment of the impact of eczema of quality of life (e.g. itchiness, sleep, life engagement, and appearance concerns).
The care plans also use behaviour change techniques, including confidence ratings and implementation intentions to help increase treatment adherence and allow a health professional to identify whether the current treatment plan is likely to be suitable for a family.
If eczema treatments are going to be effective it is important to have a breadth of knowledge in all aspects of eczema, including current research, best practice and current guidance, and access to appropriate resources. It is vital to work with children, young people and their families to ensure they have the skills and knowledge to understand how best to manage their condition, how to deal with flare-ups, adjust treatments, improve their lifestyles and access healthcare services appropriately. Information provided should be easily accessible and meaningful.
When treatments appear not to be effective changing to an alternative is not always the answer, consider all the issues highlighted in this article (Lawton, 2014).
- Eczema Outreach Support: https://www.eos.org.uk
- Nottingham Support Group for Carers of Children with Eczema: http://www.nottinghameczema.org.uk/index.aspx
- National Eczema Society: https://eczema.org
- British Association of Dermatologists (BAD): https://www.bad.org.uk/
- British Dermatological Nursing Group (BDNG): https://bdng.org.uk/
- Primary Care Dermatology Society (PCDS): https://www.pcds.org.uk/
- DermNetNZ: https://dermnetnz.org
- Patient Oriented Eczema Measure (POEM): http://nottingham.ac.uk/research/groups/cebd/resources/poem.aspx
- Recap of atopic eczema (RECAP): https://www.nottingham.ac.uk/research/groups/cebd/resources/recap.aspx
- Both the above RECAP and POEM are incorporated into the Eczema Tracker: Apple: https://apps.apple.com/gb/app/my-eczema-tracker/id1625064227 Google: https://play.google.com/store/apps/details?id=my.eczema.tracker
- University of Cardiff Department of Dermatology Quality-of-life tools: http://www.dermatology.org.uk/quality/quality-life.htm
- Eczema Record Sheet: https://www.nottingham.ac.uk/research/groups/cebd/documents/methodological-resources/nottinghameczemarecordsheet.pdf
- NICE (2007 and update 2023) Atopic eczema in under 12s: diagnosis and management Clinical guideline [CG57]: https://www.nice.org.uk/guidance/cg57
- NICE (2021) Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing NICE guideline [NG190]: https://www.nice.org.uk/guidance/ng190
- NICE (2004) Tacrolimus and pimecrolimus for atopic eczema Technology appraisal guidance [TA82]: https://www.nice.org.uk/guidance/ta82
- Atopic eczema affects 15–30% of children with around 70–90% of cases occurring before 5 years of age
- A stepped approach to management is recommended, with two treatments (emollients and topical steroids) used well forming the basis for treating eczema
- Barriers to treatment adherence include the time-consuming nature of caring for a child with eczema, and/or parental beliefs and misconceptions regarding the safety or efficacy of treatments
- Written care plans and demonstrations can help families understand and be able to self-manage their child's eczema
CPD reflective questions
- What changes do I need to make in order to assess and provide a clear plan of care for children, young people and their families presenting with eczema?
- How can I facilitate and signpost children, young people and their families with eczema to appropriate information and support to ensure they are able to self-manage the eczema?
- How can I introduce care plans for children and young people with eczema into practice?