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Skin and nail

Eczema - atopic

Last revised in August 2026

Atopic eczema is a chronic, itchy, inflammatory skin condition that affects people of all ages, although it presents most frequently in childhood.

Eczema - atopic: Summary

  • Atopic eczema is a chronic, itchy, inflammatory skin condition that affects people of all ages, although it presents most frequently in childhood. Around 70–90% of cases occur before 5 years of age, with a high incidence of onset in the first year of life.
  • It is typically an episodic disease of flares (exacerbations, which may occur as frequently as two or three times each month) and remissions; in severe cases, disease activity may be continuous. 
  • Atopic eczema is a complex condition. Genetic predisposition, skin barrier dysfunction, environmental factors (such as exposure to pets, house-dust mites, and pollen), and immune system dysfunction are thought to play a role in its development.
  • Complications include:
    • Infection, such as bacterial infection with Staphylococcus aureus, herpes simplex virus infection (may be widespread if eczema herpeticum), or superficial fungal infection.
    • Psychosocial issues, such as missing school, depression, disturbed sleep, and reduced self-confidence.
  • The diagnosis of atopic eczema is primarily clinical. Investigations are not routinely required but may be useful in excluding differential diagnoses.
  • At each consultation, the severity of the eczema and the psychological impact should be assessed.
  • A stepped approach is recommended for the management of atopic eczema:
    • Emollients are the first-line treatments during both acute flares and remissions of the condition.
    • The use of topical steroids should be considered for red, inflamed skin. The lowest potency and amount of topical corticosteroid necessary to control symptoms should be prescribed, depending on the severity of the flare. 
    • If there is persistent, severe itch, or urticaria, a one-month trial of a non-sedating antihistamine should be considered.
    • If itching is severe and affecting sleep, a short course of a sedating antihistamine should be considered (if appropriate).
    • If there is severe, extensive eczema, a short course of oral corticosteroids should be considered.
    • If eczema is weeping, crusted, or there are pustules, with fever or malaise, secondary bacterial infection should be considered, and antibiotic treatment should be prescribed. 
  • Providing appropriate information on the nature of eczema and advice on the importance of adherence to skin care measures and avoidance of trigger factors (where possible) is essential for disease maintenance and management of flares.
  • Immediate hospital admission should be arranged if eczema herpeticum (characterized by rapidly worsening, painful eczema; clustered blisters; and punched out erosions) is suspected.
  • Referral to a dermatologist should be considered if:
    • The diagnosis is uncertain.
    • Eczema is not controlled with current treatment.
    • There is recurrent secondary infection.
    • There is a high risk of complications. 
    • Treatment advice is needed (such as bandaging techniques).
  • Referral to an immunologist, paediatrician, or dermatologist should be considered if a food allergy trigger is suspected and the expertise to diagnose and manage food allergy is not available in primary care.
  • Referral to a clinical psychologist should be arranged for people whose eczema is controlled but whose quality of life and psychological well-being have not improved (this may not be directly related to the severity of the eczema).

Have I got the right topic?

From age 1 month onwards.

This CKS topic is based largely on the National Institute for Health and Care Excellence (NICE) guideline Atopic eczema in under 12s: diagnosis and management  [NICE, 2007a]. NICE reviewed the guideline in March 2021 and found no new evidence to warrant a change in recommendations.

This CKS topic covers the diagnosis, assessment, and management of atopic eczema in primary care.

This CKS topic does not cover in detail the specialist or secondary care management of atopic eczema.

There are separate CKS topics on Angio-oedema and anaphylaxis, Asthma, Conjunctivitis - allergic, Dermatitis - contact, Seborrhoeic dermatitis, and Urticaria.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

September 2026 — minor update. Minor changes to information on emollients. 

Previous changes

September 2026 — minor update. Minor changes to information on emollients.

June 2026 — minor update. Text removed related to comparisons between differing emollients.

March 2025 — minor update. Revised link to National Eczema Society website. 

July 2024 — minor update. Removed Calmurid cream as an option in emollients as this is no longer manufactured. 

May 2024 — minor update. Information added stating that concomitant treatment with clarithromycin and ivabradine is now contra-indicated and caution is now advised when co-administering clarithromycin with edoxaban, as per the manufacturer's updated SPC.

March 2024 — minor update. Link added to the National Eczema Society regarding the advice not to use aqueous cream as an emollient. 

December 2023 — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer's Summary of Product Characteristics (SPC). Recommendations relating to COVID-19 infection have been removed from this topic.

November 2023 — minor update. Interactions section for flucloxacillin updated in line with updated manufacturer's summary of product characteristics.

October 2023 — minor update. Added manufacturer's SPC link to the erythromycin suspension prescribing section. 

September 2023 — minor update. Information that aqueous cream can be used as a soap substitute has been removed from this topic in line with updated advice from the National Eczema Society and withdrawal of the SPS article Using aqueous cream as a soap substitute for skin washing.

April 2023 — minor update. A link to an online resource about eczema has been added to this topic.

April 2022 — reviewed. An updated literature review was conducted in February 2022 to identify evidence-based guidelines, UK policy statements, systematic reviews, meta-analysis studies, and key randomized controlled trials published since the last full revision of this topic. Updated literature has been incorporated to provide supporting evidence for the guidance. A prescribing information section for topical calcineurin inhibitors has been added. Minor changes to prescribing advice in line with updated manufacturer guidance, and current recommendations in the British National Formulary. No major changes to the clinical recommendations have been made.

July 2021 — Minor update. A typographical error has been corrected and a hyperlink has been updated.

March 2021 — minor update. Updated to align with NICE [NG190] Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing.

January 2021 — minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update. 

April 2020 — minor update. New management scenario created to provide information regarding COVID-19. 

January 2018 — minor update. Adverse effect section of non-sedating antihistamines updated to reflect changes to SPC.

March 2017 — reviewed. A literature search was conducted in February 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic. No major changes to clinical recommendations have been made, but the topic has been restructured.

October 2016 — minor update. Information on the risk of fire from using large amounts of paraffin-based emollients has been added, based on information in the Summary of Product Characteristics (SPC) for E45® Cream (ABPI, 2016). 

July 2015 — minor update. The prescribing information sections on erythromycin and clarithromycin have been clarified.

March 2013 — reviewed. A literature search was conducted in January 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic. No major changes to clinical recommendations have been made; however, a link to the National Institute for Health and Care Excellence (NICE) guideline Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community settings (NICE, 2011) has been provided for information on how to diagnose and manage a suspected food allergy in primary care.

June 2012 — minor update. Minor typographical error corrected.

February 2012 — minor update. Strength and generic name of Dermovate® corrected in prescribing information.

September 2011 — minor update. The recommendation on when to swab people with eczema has been clarified. 

July 2011 — minor update. Typographical errors corrected in the sections on treatment of moderate flares of eczema and advice for people using emollients and topical corticosteroids. 

June 2011 — minor update. Additional recommendations from the Scottish Intercollegiate Guidelines Network (SIGN) guideline Management of atopic eczema in primary care (SIGN, 2011) have been incorporated into this topic.

October 2010 — technical update. The management section of this topic has been simplified to improve clarity and navigation. There have been no changes to the clinical content or meaning of the recommendations.

October 2010 — minor update. Chlorphenamine is no longer licensed for the treatment of pruritus. Text and prescriptions amended to reflect this. Issued in October 2010.

November 2008 — minor update to usage instructions for diprobase cream.

March to July 2008 — converted from CKS guidance to CKS topic structure. The evidence base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. Prescriptions for emollients and topical corticosteroids have been reduced in scope to only include the most commonly prescribed products, as it is not feasible (or helpful to prescribers) to include all available products. Prescriptions for sedating antihistamines, non-sedating antihistamines, and topical antibiotics have been added in accordance with NICE recommendations.

September 2008 — minor update to text. 

February 2006 — minor update to include prescriptions for Hydromol® emollient products.

November 2005 — minor technical update. 

February 2005 — minor formatting update. Desoximetasone 0.05% oily cream discontinued and prescriptions removed.

July 2004 — written. Validated in September 2004 and issued in November 2004.

Update

New evidence

Evidence-based guidelines

HTAs (Health Technology Assessments)

No new HTAs published since 1 April 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 April 2022.

Systematic reviews and meta-analyses

  • Drucker AM, Lam M, Prieto-Merino D, et al. (2024) Systemic Immunomodulatory Treatments for Atopic Dermatitis: Living Systematic Review and Network Meta-Analysis Update. JAMA Dermatology. https://jamanetwork.com/ [Free Full-text]

Primary evidence

  • Santer, M., Muller, I., Becque, T., et al. (2022) Eczema Care Online behavioural interventions to support self-care for children and young people: two independent, pragmatic, randomised controlled trials. BMJ www.bmj.com [Free Full-text]
  • Chu, D.K., Chu, A.W.L., Rayner, D.G., et al. (2023) Systemic treatments for atopic dermatitis (eczema): systematic review and network meta-analysis of randomized trials. Journal of Allergy and Clinical Immunology, 152(6), 1470-1492. [Free Full-text]
  • Bissonnette, R., Warren, R. B., Pinter, A., et al. (2024). Efficacy and safety of delgocitinib cream in adults with moderate to severe chronic hand eczema (DELTA 1 and DELTA 2): results from multicentre, randomised, controlled, double-blind, phase 3 trials. The Lancet. [Free Full-text]
  • Simpson, E.L., Eichenfield, L.F., Alonso-Llamazares, J., et al. (2024) Roflumilast Cream, 0.15%, for Atopic Dermatitis in Adults and Children: INTEGUMENT-1 and INTEGUMENT-2 Randomized Clinical Trials. JAMA Dermatology. https://jamanetwork.com [Free Full-text]

New policies

No new national policies or guidelines since 1 April 2022.

New safety alerts

  • MHRA (2023) Janus kinase (JAK) inhibitors: new measures to reduce risks of major cardiovascular events, malignancy, venous thromboembolism, serious infections and increased mortality. Medicines and Healthcare products Regulatory Agency. www.gov.uk [Free Full-text]

Changes in product availability

  • New product Adtralza (tralokinumab): This new formulation of tralokinumab, an alternative to the pre-filled syringes, is licensed for the treatment of moderate-to-severe atopic dermatitis in adult and adolescent patients 12 years and older who are candidates for systemic therapy. See more here.
  • New product: Ebglyss (lebrikizumab) pre-filled pens and syringes. This immunoglobulin (IgG4) monoclonal antibody that binds with high affinity to interleukin-13 is licensed for treatment of moderate-to-severe atopic dermatitis in adults and adolescents ≥12 years of age with body weight of at least 40 kg who are candidates for systemic therapy. See more here.
  • New product metosyn is suitable for treating a wide variety of inflammatory, pruritic and allergic disorders of the skin. See more here.
  • Delgocitinib approved to treat adult patients with moderate to severe chronic hand eczema. See more here.
  • New product Anzupgo 20 mg/g cream (delgocitinib).This pan Janus kinase inhibitor is licensed for the treatment of moderate to severe chronic hand eczema in adults for whom topical corticosteroids are inadequate or inappropriate. See more here.
  • New product Ovixan cream is indicated for the treatment of inflammatory and pruritic manifestations of atopic dermatitis in adults, elderly patients, and children. See more here.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a diagnosis of atopic eczema.
  • Assess the physical severity of atopic eczema and associated psychological impacts.
  • Manage a person with atopic eczema during and between flares of the condition.
  • Provide information and education on atopic eczema for the person and/or their parents/carers.
  • Appropriately refer people who require further assessment and/or specialist or secondary care treatment.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

  • Children 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.
  • Children with atopic eczema are offered treatment based on recorded eczema severity using the stepped-care plan, supported by education.
  • Children with atopic eczema have their (and their families) psychological wellbeing and quality of life discussed and recorded at each eczema consultation.
  • Children with atopic eczema are prescribed sufficient quantities (250–500 g weekly) from a choice of unperfumed emollients for daily use.
  • Children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema are referred for specialist dermatological advice.
  • Infants 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 allergies.
  • Children with atopic eczema who have suspected eczema herpeticum receive immediate treatment with systemic aciclovir and are referred for same-day specialist dermatological advice.

[NICE, 2013]

Background information

What is it?

  • Atopic eczema (also known as atopic dermatitis) is a chronic inflammatory skin condition that affects people of all ages, although it most frequently presents in early childhood (mostly before 5 years of age).
  • It is characterised by dry, pruritic skin, and is typically an episodic disease of flares (exacerbations, which may occur as frequently as two or three times each month) and remissions; in severe cases, disease activity may be continuous.
  • The term 'atopic' is used to describe a group of conditions (eczema, asthma, hay-fever, and food allergy) that are linked by an increase in the allergy response activity of the immune system.
  • A personal or familial history of other atopic conditions is common among those with atopic eczema.
  • The term 'eczema' comes from the Greek word 'to boil' and is used to describe itchy, red, dry skin which can sometimes become weeping, blistered, crusted, scaling, and thickened.

[NICE, 2007a; Eichenfield, 2014a; Nankervis, 2016; Primary Care Dermatology Society, 2016; Werfel, 2016; Wollenberg, 2016; BAD, 2017; Wollenberg, 2018; BMJ Best Practice, 2022] 

What causes it?

  • There is no known single cause for atopic eczema. It is a complex condition involving genetic, immunologic, and environmental factors, leading to a dysfunctional skin barrier and immune system dysregulation [Primary Care Dermatology Society, 2016; Wollenberg, 2018].
    • There is substantial evidence indicating a strong genetic susceptibility:
    • It is likely that a number of genes contribute towards atopic susceptibility. Research suggests that mutations in the filaggrin gene are a likely cause for almost 50% of cases of atopic eczema [Tollefson, 2014; Nutten, 2015]:
      • The filaggrin gene is essential for the conversion of keratinocytes to the protein/lipid squames that make up the outermost barrier layer of the skin; the stratum corneum. Loss of filaggrin function causes skin barrier dysfunction.
    • As the primary function of the skin barrier is to restrict water loss and to prevent entry of irritants, allergens, and skin pathogens, the resulting skin barrier dysfunction is thought to [Baron et al, 2012; Tollefson, 2014; Nutten, 2015]:
      • Cause water loss from the skin, leading to dryness and itching.
      • Make the skin susceptible to allergens, leading to hyperreactivity and induction of immunoglobulin E (IgE) autoantibodies. 
      • Predispose the skin to colonization or infection by microbes, such as Staphylococcus aureus, also leading to an inflammatory response and further damage to the skin barrier. 
    • Other genetic factors have also been associated with atopic dermatitis susceptibility, including polymorphisms in genes encoding the beta subunit of the IgE receptor and cytokines expressed by Th2 cells (interleukin-3, -4, -5, -13 and granulocyte macrophage colony stimulating factor) [Meagher, 2010; Kantor, 2017].
    • Another theory is that T-helper cell dysregulation (a predominance of Th2 cells rather than Th1) results in production of IgE and mast cell hyperactivity, leading to the development of pruritus, inflammation, and other clinical features of atopic eczema [Tollefson, 2014]  [Strathie, 2016].
    • There is an increased rate of atopic eczema in urban areas, smaller families, and higher socio-economic classes, supporting the role of environmental factors in the development of this condition in susceptible individuals [BMJ Best Practice, 2022].
      • These include early life exposure to irritants, pruritogens, harsh climate factors, airborne pollutants and tobacco smoke [Kantor, 2017].
  • Several factors have been proposed as triggers for atopic eczema [NICE, 2007a; Primary Care Dermatology Society, 2016; BMJ Best Practice, 2022].
    • Possible trigger factors include soap and detergents, animal dander, house-dust mites, extreme temperatures, rough clothing, pollen, certain foods, skin infections and stress.
    • While most triggers lead to reactions confined to the skin, allergic triggers can induce both skin and systemic responses. These responses are largely mediated via IgE and T cell responses causing immediate (type 1) allergic reactions and/or delayed (late-phase or type 4) allergic reactions.
      • Immediate reactions can lead to erythema and itching, urticaria (hives), and/or angioedema, resulting in an acute flare of atopic eczema. Systemic effects involving the gastrointestinal tract (GIT, oral itching, vomiting, diarrhoea, and/or abdominal pain), the respiratory tract (rhinitis, wheeze, cough, and difficulty breathing), or the cardiovascular system (drop in blood pressure and/or collapse) may also occur. The involvement of breathing difficulties or hypotension constitutes an anaphylactic reaction. For more information see the CKS topic on Angio-oedema and anaphylaxis.
      • Delayed reactions cause itching and flares of atopic eczema and may be accompanied by GIT symptoms (vomiting and/or diarrhoea).
    • For more information on trigger factors, see the section on Identifying trigger factors.

[NICE, 2007a; Eichenfield, 2014a; Tollefson, 2014; Lyons, 2015; Ng, 2015; Nutten, 2015]  [Nankervis, 2016; Primary Care Dermatology Society, 2016; Stein, 2016; Strathie, 2016; BAD, 2017; BMJ Best Practice, 2022; Meagher, 2010; Kantor, 2017]

How common is it?

What are the complications?

Complications of atopic eczema include:

  • Infection 
    • Bacterial infection with Staphylococcus aureus may present as typical impetigo or as worsening of eczema (with increased redness, oozing, and crusting of the skin).
    • Herpes simplex infection, indicated by grouped vesicles and punched-out erosions, may occur. Disseminated herpes simplex virus infection (eczema herpeticum) presents with widespread lesions that may coalesce into large, denuded, bleeding areas that can extend over the entire body, occasionally complicated by secondary infection with staphylococcal or streptococcal species. 
      • Fever, lymphadenopathy, and malaise are common with eczema herpeticum [Lyons, 2015]. 
      • It is a medical emergency, especially in children under two years of age, and requires urgent referral for diagnosis and management. It can have serious sequelae, such as eye or meningeal involvement resulting in scarring [Strathie, 2016].
      • Risk factors for eczema herpeticum include early-onset and severe atopic eczema, marked elevations in total immunoglobulin E (IgE), elevated allergen-specific IgE levels, peripheral eosinophilia, and the presence of filaggrin mutations [Lyons, 2015].
    • Superficial fungal infections are more common in people with atopic eczema.
  • Psychosocial problems 
    • Atopic eczema causes considerable distress, and depression has been reported in both teenagers and adults with atopic eczema.
    • Preschool children with atopic eczema have higher rates of behavioural problems, fearfulness, and dependency on their parents, than unaffected children.
    • School children with atopic eczema have problems including time away from school, impaired performance, social restrictions, teasing, and bullying.
    • Atopic eczema can be associated with poor self-image and self-confidence that can impair social development. Among children with moderate-to-severe eczema attending outpatient departments, psychological problems are double that of school children without eczema.
    • Sleep disturbance is a major problem for people with atopic eczema and their families.
  • Other atopic and non-atopic comorbidities
    • Atopic eczema has been found to be associated with numerous atopic comorbidities, including asthma, allergic rhinitis (hay fever), food allergy, and eosinophilic oesophagitis [Silverberg, 2019].
      • Increased severity in infancy and persistent disease has been associated with greater risks of food allergy (particularly to egg and peanut) [Tsakok, 2016].
    • Other non-atopic comorbidities associated with atopic eczema include allergic contact dermatitis, obesity and cardiovascular disease [Silverberg, 2019].

[NICE, 2007a; Simpson, 2010; Eichenfield, 2014a; Tollefson, 2014; Lyons, 2015; Kim, 2016; Nankervis, 2016; Primary Care Dermatology Society, 2016; Stein, 2016; Strathie, 2016; Werfel, 2016; BAD, 2017; Silverberg, 2019; BMJ Best Practice, 2022; Cork, 2020; Tsakok, 2016; Zeiser, 2020]

What is the prognosis?

  • Atopic eczema is typically an episodic disease of flares (exacerbations, which may occur as frequently as two or three times each month) and remissions. In severe cases (2–6% of cases), disease activity may be continuous [NICE, 2007a].
  • Atopic eczema has a tendency to gradual improvement in adult life [NICE, 2007a; Abuabara, 2019].
    • The condition can be expected to clear in about 65% of children by the time they are 7 years of age and in about 74% of children by 16 years of age [Primary Care Dermatology Society, 2016], although relapses may occur [NICE, 2007a; Werfel, 2016; Silverberg, 2019].
    • A systematic review and meta-analysis assessed the persistence rates of atopic eczema in 110, 651 participants from 15 countries [Kim, 2016]:
      • In pooled analysis, 80% of childhood atopic eczema did not persist by 8 years of age and less than 5% persisted by 20 years after diagnosis.
      • The authors concluded that most childhood atopic eczema remitted by adulthood. However, children with already persistent disease, later onset, and/or more severe disease were more likely to experience further disease persistence. 
    • Most cases of atopic eczema are regarded as mild, with less than 10% of patients suffering from severe eczematous skin lesions [Wollenberg, 2018]. This percentage of severe cases may be higher in adults with atopic eczema  [Wollenberg, 2018].
  • Many children with atopic eczema will go on to develop asthma (30–50%) and/or hay fever (30–80%)  [Nankervis, 2016; BAD, 2017; Silverberg, 2019; BMJ Best Practice, 2022]. This sequence of events is sometimes referred to as the 'atopic March' [NICE, 2007a].

Diagnosis of atopic eczema

How should I diagnose atopic eczema?

  • Take a history. Ask about:
    • The presence of itching — the diagnosis is unlikely to be atopic eczema if there is no itch.
    • The pattern, time of onset, and natural history of the rash — atopic eczema usually starts in infancy and is episodic in nature. 
    • A family or personal history of atopy — allergic rhinitis and asthma are associated with atopic eczema.
    • Any treatments(s) tried and the response to the treatment(s).
    • Possible trigger factors (irritant or allergic). See the section on Identifying trigger factors for more information.
  • Examine the rash. 
    • The distribution and appearance of the rash will be influenced by the person's age, ethnicity, duration of the rash and the presence/absence of infection. Signs of excoriation may also be present.
      • In adults, there is generalized dryness and itching, particularly with exposure to irritants. Eczema on the hands may be the primary manifestation.
      • In children and adults with long-standing disease, eczema is often localized to the flexure of the limbs.
      • In infants, eczema primarily involves the face, the scalp, and the extensor surfaces of the limbs. The nappy area is usually spared.
      • Acute eczema (flares) varies in appearance, from poorly demarcated redness to fluid in the skin (vesicles), scaling, or crusting of the skin.
      • Chronic eczema is characterized by thickened (lichenified) skin resulting from repeated scratching. Follicular hyperkeratotic papules (keratosis pilaris) that are typically asymptomatic may be present on the extensor surfaces of the upper arms, buttocks, and anterior thighs.
    • If eczema is weeping, crusted, or there are pustules, with fever or malaise, secondary bacterial infection should be considered. See Scenario: Infected eczema for management information.
  • The National Institute for Health and Care Excellence (NICE) states that atopic eczema is likely if the following criteria are fulfilled, although alternative diagnoses may need to be excluded:
    • An itchy skin condition (or parental report of scratching) plus three or more of the following:
      • Visible flexural eczema involving the skin creases, such as the bends of the elbows or behind the knees (or visible eczema on the cheeks and/or extensor areas in children aged 18 months or younger).
      • Personal history of flexural eczema (or eczema on the cheeks and/or extensor areas in children aged 18 months or younger).
      • 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 a child aged under 4 years).
      • Onset of signs and symptoms before the age of 2 years (this criterion should not be used in children younger than 4 years of age).
    • Note that these criteria apply to all ages, social classes, and ethnic groups. However, in children of Asian, black Caribbean, and black African ethnic groups, atopic eczema can affect the extensor surfaces rather than the flexures, and discoid (circular) or follicular (around the hair follicles) patterns may be more common.
  • Investigations are not required to establish the diagnosis of atopic eczema. However, they may be useful in excluding differential diagnoses, especially in people whose symptoms do not respond to treatment.
  • If atopic eczema is diagnosed, assess:

Basis for recommendation

These recommendations are largely based on expert opinion in the National Institute for Health and Care Excellence (NICE) guideline Atopic eczema in under 12s: diagnosis and management [NICE, 2007a]. NICE reviewed this guideline in March 2021 and found no new evidence to warrant a change in recommendations (for diagnosis). CKS has extrapolated the recommendations to include the management of older children and adults. 

These recommendations are also in line with those in Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011], Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis published by the American Academy of Dermatology (AAD) [Eichenfield, 2014a], S2k guideline on diagnosis and treatment of atopic dermatitis - short version (a German guideline supported financially by the German Dermatology Society [DDG]) [Werfel, 2016], and in review articles on atopic eczema [Tollefson, 2014; Lyons, 2015; Strathie, 2016].

History and examination

Excluding other conditions

Investigations not routinely required

  • Expert opinion in an American guideline is that skin biopsies and laboratory testing are usually unnecessary and not helpful in making the diagnosis of atopic eczema. However, they may be beneficial when trying to exclude differential diagnoses, especially in people whose symptoms are not responding to treatment [Tollefson, 2014].

How should I identify trigger factors for atopic eczema?

  • Many different factors have been proposed as triggers for atopic eczema. Triggers are thought to increase the incidence of atopic eczema and/or exacerbate the symptoms of established disease.
    • The identification of trigger factors is crucial for the management of atopic eczema as avoidance may allow for longer periods of symptom remission.
  • To identify possible trigger factors, ask about (or assess for) the following:
    • Irritant allergens — ask about changes in soaps and detergents, especially in people with previously well-controlled eczema.
    • Irritant clothing — be aware that some fabrics can act as irritant allergens. For example:
      • Synthetic fabrics and wool tend to itch and irritate the skin.
      • Silk fabric is often closely woven, thereby impeding the flow of air, and some people are allergic to the sericin protein in silk.
      • Cotton fabric is usually recommended; however, its structure contains short fibres which expand and contract, causing a rubbing movement that can irritate delicate skin. The dyes used in coloured cotton garments can increase the risk of a sensitivity reaction.
    • Skin infections — Staphylococcus aureus is implicated as both a causal factor and a trigger factor for atopic eczema. Other organisms implicated include streptococcus species, Candida albicans, Pityrosporum yeasts, and herpes simplex.
    • Contact allergens — ask about preservatives in topical medications, perfume-based products, metals, and latex.
      • Consider the possibility of allergic contact dermatitis in people with an exacerbation of previously controlled atopic eczema, or with reactions to topical treatments. For more information, see the CKS topic on Dermatitis - contact. 
    • Inhalant allergens — ask about symptoms around pets and pollen, especially in older children and adults with seasonal flares, asthma, or rhinitis, and in children over 3 years of age with atopic eczema on the face, especially around the eyes. Sensitivity to airborne allergens may result in presentations with flares on the head and neck.
    • Hormonal triggers — be aware that changes in hormone levels can affect the symptoms of atopic eczema in some women, for example premenstrual flares of eczema can occur, and pregnancy can adversely affect eczema in some women.
    • Climate — extremes of temperatures can affect atopic eczema. There is a seasonal variation in the pattern of atopic eczema, and most people are aware of improvements in their eczema during the summer (with worsening symptoms in the winter). Sweating induced by heat or exercise can provoke a flare of eczema at any time of year.
    • Concurrent illness and disruption to family life — teething, emotional stress, ill health, and lack of sleep can affect the symptoms of atopic eczema.
    • Dietary factors — ask about itch or redness after certain foods (immediately or hours later), diarrhoea, vomiting, and/or poor weight gain. Milk, egg, wheat, soy, and peanut account for about 75% of the cases of food-induced atopic eczema. 
      • Consider asking the person to keep a food diary over 4–6 weeks. In infants, also ask about feeding history (weaning, breastfeeding, or bottle feeding).
      • Suspect food allergy in children with atopic eczema who have reacted previously to a food, with immediate symptoms, or in infants and young children with moderate or severe atopic eczema that has not been controlled by optimum management, particularly if associated with gut dysmotility (colic, vomiting, altered bowel habit) or failure to thrive.
  • Most people do not need allergy testing. 
    • Advise avoidance of over-the-counter tests as these are of no proven value.
    • If a food allergy is suspected, manage in primary care if the expertise and support are available, otherwise refer to secondary care.
    • If other types of allergies are suspected, refer to secondary care as appropriate.

Basis for recommendation

These recommendations are largely based on expert opinion in the National Institute for Health and Care Excellence (NICE) guideline Atopic eczema in under 12s: diagnosis and management [NICE, 2007a]. NICE reviewed this guideline in March 2021 and found no new evidence to warrant a change in recommendations. CKS has extrapolated the recommendations to include the management of older children and adults. 

These recommendations are also in line with expert opinion in review articles on atopic eczema [Wollenberg, 2018].

Trigger factors

  • Irritant allergens, including irritant clothing
    • A European consensus guideline on the management of atopic eczema highlighted the potential for mechanical irritants (wool clothing), household chemicals, and biological allergens (microbes, pollen) to aggrevate the skin in those with atopic eczema [Wollenberg, 2018].
    • Expert opinion in a review article is that soaps, detergents, and chemicals reduce the already depleted lipid barrier on the skin or may act directly as an allergen [Beltrani and Boguneiwicz, 2003].
    • The information on the effect of different fabrics is based on expert opinion in a review article [Mason, 2008].
  • Skin infections
    • Staphylococcus aureus is the most common pathogen isolated in people with atopic eczema [Lyons, 2015; Strathie, 2016].
    • Evidence from a systematic review and meta-analysis that evaluated the prevalence and odds of skin and nasal colonization with S. aureus demonstrated that people with atopic eczema are more likely to be colonized with S. aureus than healthy controls [Totté, 2016].
  • Inhaled allergens
    • Information on specific inhaled allergens is based on expert opinion in a review article [Beltrani and Boguneiwicz, 2003] and has also been described in a European consensus guideline on the management of atopic eczema [Wollenberg, 2018].
  • Hormonal triggers
    • Changes in hormone levels can affect the symptoms of atopic eczema in some women [Beltrani and Boguneiwicz, 2003; MaHTAS, 2018]:
      • The natural Th2 predominance of the immune system in pregnancy can increase atopy in some women.
      • Malaysian clinical guidelines state that up to 25% of pregnant women experience an improvement in their symptoms, more than 50% deteriorate during pregnancy and 10% suffere a flare in their condition during the post-partum period.
      • Pregnancy was noted to have an adverse effect on 52% of women with atopic eczema, during the first and second trimester (improvement was noted in the third trimester).
      • A prospective study of 200 pregnant women reported a very high prevalence of eczema.
      • In a questionnaire survey, 30% of women reported premenstrual flares of atopic eczema.
  • Dietary factors
    • Dietary factors may play a role in the exacerbation on atopic eczema, especially in younger children [Lyons, 2015].
    • Expert opinion in the NICE guideline on Food allergy in children and young people is that the possibility of a food allergy should be considered in people with atopic eczema [NICE, 2011a]. 
    • Milk, egg, wheat, soy, and peanut account for 75% of the cases of food-induced atopic eczema [Greenhawt, 2010; Strathie, 2016].
    • The recommendation on when to consider a food allergy is based on the NICE guidelines Atopic eczema in under 12s: diagnosis and management [NICE, 2007a] and Food allergy in children and young people [NICE, 2011a].
  • Air pollutants
    • A European consensus guideline on the management of atopic eczema highlighted the potential for both indoor and outdoor air polutants (such as tobacco smoke, volatile organic compouds like formaldehyde, traffic exhaust fumes) to aggrevate the skin in those with atopic eczema [Wollenberg, 2018].
  • Animal epithelia
    • A European consensus guideline on the management of atopic eczema highlighted the potential for cat epithelia exposure as a risk factor for deterioration of skin symptoms in those with atopic eczema. There is no evidence that dogs increase the risk of atopic eczema in children, and may be protective. Once a patient is sensitized to a pet and shows symptoms, avoidance is recommended [Wollenberg, 2018].

Allergy testing

  • The NICE Guideline Development Group could not find any trials examining the accuracy of tests for diagnosing inhalant allergies, or tests investigating reactions to climatic, psychological, or environmental triggers in atopic eczema [NICE, 2007b].
  • Expert opinion in review articles is that testing for food allergy is not routinely recommended due to the low positive predicitve value of both skin testing and in vitro serum assays for allergen-specific immunoglobulin E (IgE) [Eichenfield, 2015; Lyons, 2015].
    • CKS recommends that allergy testing investigations are not routinely required to establish the diagnosis of atopic eczema. However, in line with other expert opionion guidelines [BMJ Best Practice, 2022], they may be useful in excluding differential diagnoses, particularly in people whose symptoms do not respond to treatment, or where the identification of trigger factors has proved problematic.
  • NICE recommends that if a food allergy is suspected, a healthcare professional with the appropriate competencies should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person. Management will depend on the results of this [NICE, 2011b].
    • CKS recommends that if the expertise and support are not available in primary care, referral to secondary care should be made.

What else might it be?

  • Differential diagnoses of atopic eczema include:
    • Psoriasis — less itchy, well-circumscribed, reddish, flat-topped plaques with silvery scales; typically symmetrical. For more information, see the CKS topic on Psoriasis.
    • Allergic contact dermatitis — eczematous rash, at any site related to a topical allergen, in a person of any age. Allergic contact dermatitis can be both an alternative diagnosis and a trigger factor of atopic eczema. For more information, see the CKS topic on Dermatitis - contact. 
    • Seborrhoeic dermatitis — red, sharply marginated lesions with greasy scales; usually confined to areas with sebaceous gland activity (for example ears, beard area, eyebrows, scalp, and nasolabial folds). For more information, see the CKS topic on Seborrhoeic dermatitis.
    • Fungal infection — annular patch or plaque with slightly raised, sometimes scaly, border, and central clearing. For more information, see the CKS topics on Fungal skin infection - body and groin, Fungal skin infection - foot, and Fungal skin infection - scalp. 
    • Scabies or other infestations — should be suspected when there is recent onset of an itchy rash in a family. For more information, see the CKS topic on Scabies.
    • Food allergy — could be suspected in children and young people who have not responded to conventional treatment for atopic eczema. For more information, see the CKS topic on Food allergy.

Basis for recommendation

Information on the differential diagnoses of atopic eczema is based on expert opinion in Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis published by the American Academy of Dermatology (AAD) [Eichenfield, 2014a], and S2k guideline on diagnosis and treatment of atopic dermatitis - short version (a German guideline supported financially by the German Dermatology Society [DDG]) [Werfel, 2016], and in review articles on atopic eczema [Baron et al, 2012; Arkwright, 2013; Eichenfield, 2015; Lyons, 2015; Strathie, 2016; BMJ Best Practice, 2022].

Management

Scenario: Assessment

From age 1 month onwards.

How should I assess the severity of eczema?

  • A stepped approach to treatment is recommended for the management of atopic eczema, tailoring the treatment to the severity of the condition. See Stepped approach to treatment for more information.
  • At each consultation, assess the severity of the eczema in order to determine the most appropriate treatment. 
    • To assess the severity of the eczema, examine all areas of affected skin, and ask about itching.
    • Categorize eczema as:
      • Clear — if there is normal skin and no evidence of active eczema. 
      • Mild — if there are areas of dry skin, and infrequent itching (with or without small areas of redness). See Scenario: Mild eczema for management information.
      • Moderate — if there are areas of dry skin, frequent itching, and redness (with or without excoriation and localized skin thickening). See Scenario: Moderate eczema for management information.
      • Severe — if there are widespread areas of dry skin, incessant itching, and redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking, and alteration of pigmentation). See Scenario: Severe eczema for management information.
      • Infected — if eczema is weeping, crusted, or there are pustules, with fever or malaise. See Scenario: Infected eczema for management information.
    • Consider using validated tools to assess severity, including:
      • Visual analogue scales (0–10) of the person's assessment of severity, itch, and sleep loss over the last 3 days and nights
      • The Patient-Oriented Eczema Measure (POEM), this can be downloaded from www.nottingham.ac.uk (pdf).

Basis for recommendation

These recommendations are largely based on expert opinion in the National Institute for Health and Care Excellence (NICE) guideline Atopic eczema in under 12s: diagnosis and management [NICE, 2007a]. NICE reviewed this guideline in March 2021 and found no new evidence to warrant a change in recommendations. CKS has extrapolated the recommendations to include the management of older children and adults. 

  • Expert opinion in the NICE guideline is that an examination of all patches of eczema is needed as differing severity can co-exist on the same person, requiring independent treatment. Physical examination is also essential to determine the correct treatment.
  • The NICE Guideline Development Group (GDG) could not find any evidence on the usefulness of severity and quality of life measures for guiding treatment decisions in clinical practice. However, the GDG agreed that a structured, validated tool may prompt individuals and families about certain aspects of the condition, thereby improving communication and treatment.

How should I assess the psychological impact of eczema?

  • At each consultation, assess the psychological impact of atopic eczema. Be aware that there is not necessarily a direct relationship between the severity of the atopic eczema and the impact of the atopic eczema on quality of life.
    • To assess the psychological impact of atopic eczema, ask about the effect of eczema on daily activities (school, work, and social life), sleep, and mood.
    • Categorize the impact of eczema on quality of life and psychosocial well-being as:
      • None — no impact on quality of life.
      • Mild — little impact on everyday activities, sleep, and psychosocial well-being.
      • Moderate — moderate impact on everyday activities and psychosocial well-being, and frequently disturbed sleep.
      • Severe — severe limitation of everyday activities and psychosocial functioning, and loss of sleep every night.
    • Consider using validated tools to assess the impact of atopic eczema on quality of life, including:
  • Atopic eczema may impact the psychosocial well-being and quality of life of parents or carers, as well as the child, appropriate advice and support should be provided where required.

Basis for recommendation

These recommendations are largely based on expert opinion in the National Institute for Health and Care Excellence (NICE) guideline Atopic eczema in under 12s: diagnosis and management [NICE, 2007a]. NICE reviewed this guideline in March 2021 and found no new evidence to warrant a change in recommendations. CKS has extrapolated the recommendations to include the management of older children and adults. 

  • NICE states that an assessment of quality of life will help influence treatment choices and referral decisions. For example, if the person has only mild physical symptoms but is severely affected psychologically, a referral to secondary care is appropriate.
  • A 2019 systematic review identified the Dermatology Life Quality Index (DLQI) (for use in adults) to be insufficient in determining the quality of life of those with atopic eczema, and recommended that its use should not be continued [Gabes, 2020].

Scenario: Mild eczema

From age 1 month onwards.

How should I manage a person with mild eczema?

If a person presents with mild eczema (or an acute flare of mild eczema):

  • Prescribe appropriate treatment.
    • Prescribe generous amounts of emollients, and advise frequent and liberal use.
    • Consider prescribing a mild topical corticosteroid (such as hydrocortisone 1%) for areas of red skin. Treatment should be continued for 48 hours after the flare has been controlled.
    • See the prescribing information sections on Emollients and Topical corticosteroids for more information on emollients and topical corticosteroids, including available products and usage instructions.
  • Give appropriate information and advice, including general information on atopic eczema, measures to maintain the skin and reduce the risk of flares, self-care advice, and information on treatments not recommended. See the section on Additional information and advice for more information.
  • Active follow up is rarely required for mild eczema, unless the person or carer requests it.
    • For people with persisting eczema, consider annual review of emollient use to ensure optimal usage.
  • Refer for a routine dermatology appointment if:
    • The diagnosis is, or has become, uncertain.
    • Current management has not controlled eczema satisfactorily (for example the person is having one to two flares per month), or the person is reacting adversely to many emollients.
    • Facial eczema has not responded to appropriate treatment.
    • There is recurrent secondary infection.
  • Refer to a clinical psychologist, people whose eczema is controlled but whose quality of life and psychological well-being have not improved (this may not be directly related to the severity of the eczema).

Basis for recommendation

These recommendations are largely based on expert opinion in the National Institute for Health and Care Excellence (NICE) guideline Atopic eczema in under 12s: diagnosis and management [NICE, 2007a]. NICE reviewed this guideline in March 2021 and found no new evidence to warrant a change in recommendations. CKS has extrapolated the recommendations to include the management of older children and adults. 

These recommendations are also in line with those in Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011], Caring for children and young people with atopic eczema: guidance for nurses published by the Royal College of Nursing (RCN) [RCN, 2013], Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies published by the American Academy of Dermatology (AAD) [Eichenfield, 2014b], Atopic eczema published by the Primary Care Dermatology Society (PCDS) [Primary Care Dermatology Society, 2016], S2k guideline on diagnosis and treatment of atopic dermatitis - short version (a German guideline supported financially by the German Dermatology Society [DDG]) [Werfel, 2016], the ETFAD/EADV Eczema task force 2015 position paper on diagnosis and treatment of atopic dermatitis in adult and paediatric patients published by the European Task Force on Atopic Dermatitis (ETFAD) and European Academy of Dermatology and Venerology (EADV) [Wollenberg, 2016], European Dermatology Forum 2018 guidelines for the treatment of atopic eczema (atopic dermatitis) [Wollenberg, 2018], Japanese guidelines for atopic dermatitis published in 2020 [Katoh, 2020], Malaysian Health Technology Assessment Section 2018 guidelines on the management of atopic eczema [MaHTAS, 2018], and in review articles on atopic eczema [Arkwright, 2013; Baron et al, 2012; Tollefson, 2014; Eichenfield, 2015; Lyons, 2015; Ng, 2015]  [Stein, 2016; Strathie, 2016; BMJ Best Practice, 2022].

Prescribing appropriate treatment
  • NICE recommends a stepped approach for managing atopic eczema. This means that treatment should be tailored to the severity of the eczema, and stepped up or down according to the severity of symptoms [NICE, 2007a].
  • Emollients are almost universally recommended as first-line treatment for atopic eczema, and experts advise that they should form the basis of management and should always be used, even when the skin is clear [NICE, 2007a; SIGN, 2011; Baron et al, 2012; RCN, 2013; Eichenfield, 2014b; Eichenfield, 2015; Lyons, 2015; Ng, 2015; BMJ, 2016; Primary Care Dermatology Society, 2016; Strathie, 2016; Wollenberg, 2016].
    • A Cochrane systematic review of 77 studies (n = 6603, mean age = 18.6 years, mean duration = 6.7 weeks) assessed the effects of moisturisers for eczema [van Zuuren, 2017]:
      • The evidence suggested that most moisturisers showed some beneficial effects in prolonging time to flare, reducing the number of flares, and reducing the amount of topical corticosteroids needed to achieve similar reductions in eczema severity, producing better results when used with active treatment. However, there was no evidence that one moisturiser is better than another. 
      • Adverse events reporting was limited (smarting, stinging, pruritus, erythema, and folliculitis).
  • Topical corticosteroids are the most effective treatments to address the inflammatory component of atopic eczema [Eichenfield, 2014b; Lyons, 2015; Primary Care Dermatology Society, 2016; Wollenberg, 2016], and there is reasonable evidence of benefit for their use [Nankervis, 2016; Wollenberg, 2018].
    • It is recommended that topical corticosteroids for atopic eczema should be prescribed for application only once or twice daily [NICE, 2004a].
    • The potency of the topical steroid should be tailored to the severity of the eczema, and patient specific factors such as age and the area of the skin being treated [NICE, 2007a; Lyons, 2015; Wollenberg, 2018].
    • Healthcare professionals should discuss the benefits and harms of treatment with topical corticosteroids with people with atopic eczema, and their parents or carers, emphasising that the benefits outweigh possible harms when they are applied correctly [NICE, 2007a].
    • NICE and EDF guidelines recommend the use of mild potency corticosteroids for the face and neck [NICE, 2007a; Wollenberg, 2018].
Giving appropriate information and advice
Active follow up not required
  • These recommendations are consistent with the NICE guideline, although the specific recommendations for follow up are incomplete. Where this is the case, CKS offers guidance based on pragmatism and good clinical practice.
  • NICE states that the repeat prescribing of emollients over long periods without review should be discouraged, and annual reviews should be carried out [NICE, 2007a]. However, this may not be necessary in people with small areas of mild eczema that require minimal intervention.
Referral

What information and self-care advice on eczema should I give?

  • Provide information on atopic eczema.
    • Explain that eczema is a chronic illness characterized by flares, which can usually be controlled with appropriate treatment.
    • Also discuss that poorly managed atopic eczema can have a significant impact on psychosocial well-being.
    • Provide information on recognizing:
      • The early or prodromal signs and symptoms of a flare. Should this occur, advise immediate and aggressive treatment using an agreed stepped-care plan.
      • The symptoms and signs of eczema herpeticum, which is a medical emergency.
      • The symptoms and signs of infected eczema. 
    • In children, inform parents/carers that:
      • Eczema often improves with time. However, not all children will grow out of it, and it may get worse in teenage or adult life.
      • Children with atopic eczema can often develop asthma and/or allergic rhinitis and that sometimes food allergy is associated with atopic eczema, especially in very young children.
  • Provide instructions on the correct use of emollients, with clear demonstrations where appropriate. Also address any concerns regarding adverse effects of topical corticosteroids, if prescribed.
  • Give advice on measures to maintain the skin and reduce the risk of flares.
    • Encourage the frequent and liberal use of emollients, even during periods where the skin is clear.
      • Through decreasing symptoms of dryness, pain and itching, emollient use may also lead to a decreased exposure to bacteria and sensitising antigens.
      • Regular use of emollient therapy has been shown to have both short and long-term steroid sparing effects in mild to moderate atopic eczema.
    • Advise that where possible, they should avoid trigger factors known to exacerbate eczema, such as certain clothing (they should avoid wearing synthetic fibres), soaps or detergents (they should use emollient substitutes), animals, and heat (they should keep rooms cool).
      • House-dust mite avoidance strategies are generally not recommended as they are time consuming and of limited benefit.
    • Advise that they should avoid scratching the eczema (if possible), and simply rub the area with their fingers to alleviate itch. Nails should be kept short, and anti-scratch mittens should be used in babies with eczema.
  • Also advise the person and/or their parents/carer that:
    • They should not alter their diet unless under specialist advice.
      • Breastfeeding mothers of children with atopic eczema should not alter their diets unless under specialist advice. See the section on Breastfed and bottle-fed infants for more information.
    • Complementary therapies are not recommended for the management of atopic eczema; a healthcare professional should be informed if these are used. Also advise that:
      • Treatments such as homeopathic remedies, herbal medicine, massage, and food supplements (such as evening primrose oil) have not been adequately assessed in clinical trials.
      • All therapies that claim effectiveness (including natural remedies) may also have adverse effects.
      • Chinese herbal medicines have been associated with life-threatening adverse effects and have in some cases been contaminated with corticosteroids.
      • If they insist on using complementary therapies, they should continue using the emollients frequently and liberally, even when the skin is clear.
  • Support effective self-management of atopic eczema by addressing beliefs and concerns about treatments. These may include:
    • Seeking positive ways to promote a 'control not cure' approach to management.
    • Acknowledging the psychosocial impacts of atopic eczema and the burden of treatment.
    • Providing clear consistent advice or signposting towards reliable information about medicines and management of atopic eczema.
    • Informing people with atopic eczema, and/or their parents or carers, that the condition may temporarily affect skin pigmentation (causing the skin to become lighter or darker).
  • Provide patient information leaflets and information on eczema support groups.

Basis for recommendation

These recommendations are largely based on expert opinion in the National Institute for Health and Care Excellence (NICE) guideline Atopic eczema in under 12s: diagnosis and management [NICE, 2007a]. NICE reviewed this guideline in March 2021 and found no new evidence to warrant a change in recommendations. CKS has extrapolated the recommendations to include the management of older children and adults.

These recommendations are also in line with those in Caring for children and young people with atopic eczema: guidance for nurses published by the Royal College of Nursing (RCN) [RCN, 2013], Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies published by the American Academy of Dermatology (AAD) [Eichenfield, 2014b], Atopic eczema published by the Primary Care Dermatology Society (PCDS) [Primary Care Dermatology Society, 2016], S2k guideline on diagnosis and treatment of atopic dermatitis - short version (a German guideline supported financially by the German Dermatology Society [DDG]) [Werfel, 2016], the ETFAD/EADV Eczema task force 2015 position paper on diagnosis and treatment of atopic dermatitis in adult and paediatric patients published by the European Task Force on Atopic Dermatitis (ETFAD) and European Academy of Dermatology and Venerology (EADV) [Wollenberg, 2016], European Dermatology Forum 2018 guidelines for the treatment of atopic eczema (atopic dermatitis) [Wollenberg, 2018], Japanese guidelines for atopic dermatitis published in 2020 [Katoh, 2020], Malaysian Health Technology Assessment Section 2018 guidelines on the management of atopic eczema [MaHTAS, 2018], and in review articles on atopic eczema [Buddenkotte et al, 2010; Baron et al, 2012; Arkwright, 2013; Eichenfield, 2015; Lyons, 2015; Ng, 2015; Strathie, 2016; BMJ Best Practice, 2022].

Providing information on atopic eczema
Advice on measures to maintain the skin and reduce flares
  • Emollients are the first-line treatments for both acute flares of eczema and during remission [RCN, 2013; Eichenfield, 2014b; Ng, 2015; Primary Care Dermatology Society, 2016; Wollenberg, 2018; MaHTAS, 2018].
  • NICE states that treating dry skin (an early sign of a flare) with an emollient may prevent the flare worsening [NICE, 2007a].
    • Scratching is thought to be a major component of flare progression, as it physically damages the skin and can delay healing or facilitate infection. Emollients are believed to ease itching and thus may have a role in breaking the itch-scratch cycle [Grimalt et al, 2007; Wollenberg, 2018].
  • A Cochrane systematic review of 77 studies (n = 6603, mean age = 18.6 years, mean duration = 6.7 weeks) assessed the effects of moisturisers for eczema [van Zuuren, 2017]. The evidence suggested that most moisturisers showed some beneficial effects in prolonging time to flare, reducing the number of flares, and reducing the amount of topical corticosteroids needed to achieve similar reductions in eczema severity, producing better results when used with active treatment. However, there was no evidence that one moisturiser is better than another. 
Advice on avoiding triggers
  • Avoiding scratching — the benefit of the short-term relief by scratching the skin is counteracted by a simultaneous damage of the epidermis, leading to increased transepidermal water loss and drying, which in turn results in a cycle of more itching and more scratching [Buddenkotte et al, 2010].
  • House-dust mite avoidance — NICE does not recommend house-dust mite elimination strategies for managing atopic eczema [NICE, 2007a]. Although people with atopic eczema are often sensitized to house dust mites [Eichenfield, 2014a], there is no strong evidence that dust mite avoidance strategies are effective in treating or preventing atopic eczema:
    • A systematic review and meta-analysis (n = 3040) assessed dust mite avoidance measures for the primary prevention of atopic dermatitis and found that they provided no benefit in the prevention of atopic dermatitis [Bremmer, 2015].
    • A Cochrane systematic review (search date: August 2014) assessed the effects of house dust mite reduction and avoidance measures for the treatment of atopic eczema and was unable to determine clear implications to inform clinical practice, due to the low-quality evidence available [Nankervis, 2015].
  • Irritants, temperature, humidity, pet removal, and stress — NICE found no evidence regarding avoidance of these triggers. However, experts recommend that if these triggers exacerbate eczema, they should be avoided, where possible [RCN, 2013; BAD, 2017].
  • Dietary modification:
    • Evidence from a Cochrane systematic review (search date: March 2006) suggests that there is no benefit from milk and egg-free exclusion diets in people who do not have a known allergy to specific foods [Bath-Hextall, 2008a].
    • Expert opinion in the NICE guideline Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community settings [NICE, 2011b] is that if a food allergy is suspected, a healthcare professional with the appropriate competencies should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person. For more information, see the full NICE guideline.
    • Expert opinion in guidelines [RCN, 2013; Werfel, 2016; Wollenberg, 2018] and review articles [Lyons, 2015; Strathie, 2016] on atopic eczema is that any dietary exclusion or elimination diets should be implemented and monitored by a specialist.
    • There is limited evidence to recommend the use of few-food diets, elemental diets, probiotic supplements, sodium cromoglicate, dietary exclusion in breastfeeding women [NICE, 2007b; Lloyd-Lavery, 2016], or dietary supplements with zinc, essential fatty acids, or vitamin B6 [Bath-Hextall and Williams, 2007] for the management of atopic eczema.
Treatments not recommended
  • There is insufficient evidence to recommend complementary therapies (homeopathy, herbal medicine, massage, and food supplements) in the management of atopic eczema [RCN, 2013; NICE, 2007b; Nankervis, 2016; Wollenberg, 2018; Lu, 2018].
  • Limited evidence identified by CKS does not support the use of Chinese herbal medicine [Gu, 2013], oral evening primrose oil [Bamford, 2013], or borage oil [Bamford, 2013] for the management of atopic eczema. 
  • The Medicines and Healthcare products Regulatory Agency (MHRA) warns that the phrases 'natural', 'herbal', and 'derived from plants' do not necessarily mean that the product is 'safe'. Herbal medicines, like other medicines, can have adverse effects. They can also interact with other medicines, resulting in reduced or enhanced effects of the other medicines. For further information, see www.mhra.gov.uk/safetyinformation [MHRA, 2012].

Regular use of emollient therapy has been shown to have both short and long-term steroid sparing effects in mild to moderate atopic eczema

  • Recommendation provided in consensus-based European guidelines for the treatment of atopic eczema [Wollenberg, 2016].

Effective self-management of atopic eczema can be supported by addressing beliefs and concerns about treatments

  • Findings from a systematic review and thematic synthesis of qualitative studies which assessed the views and experiences of individuals managing atopic eczema form the basis of these recommendations [Teasdale, 2021].

Scenario: Moderate eczema

From age 1 month onwards.

How should I manage moderate eczema?

If a person presents with moderate eczema (or an acute flare of moderate eczema):

  • Consider the need for immediate admission or referral. For example:
    • Admit to hospital if eczema herpeticum (widespread herpes simplex virus) is suspected.
  • Consider the possibility of trigger factors or infection, which can precipitate or worsen a flare.
  • Prescribe appropriate treatment.
    • Prescribe a generous amount of emollients, and advise frequent and liberal use (more than usual). For more information on emollients, including available products and usage instructions, see the prescribing information section on Emollients.
    • If the skin is inflamed, prescribe a moderately potent topical corticosteroid (for example betamethasone valerate 0.025% or clobetasone butyrate 0.05%) to be used on inflamed areas. Treatment should be continued for 48 hours after the flare has been controlled. 
      • For delicate areas of skin (such as the face and flexures), consider starting with a mild potency topical corticosteroid (such as hydrocortisone 1%) and increase to a moderate potency corticosteroid only if necessary. Aim for a maximum of 5 days' use.
      • For more information on topical corticosteroids, including available products and usage instructions, see the prescribing information section on Topical corticosteroids.
    • Occlusive dressings or dry bandages may be of benefit; however, treatment should only be started by a healthcare professional trained in their use (otherwise consider referral).
    • If there is severe itch or urticaria, consider prescribing a one-month trial of a non-sedating antihistamine (such as cetirizine, loratadine, or fexofenadine).
    • If there are areas of infected skin, see Scenario: Infected eczema for management information.
  • Prescribe preventative treatment according to the usual severity of the condition between flares.
    • Consider prescribing a maintenance regimen of topical corticosteroids to control areas of skin prone to frequent flares (not recommended for the face, genitals, or axillae). Options include a 'step down approach' or 'intermittent treatment'. See the section on Maintenance regimens for more information on these regimens.
    • Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are a second-line option. However, they should only be prescribed by a specialist (including GPs with a specialist interest in dermatology).
  • Give appropriate information and advice, including general information on atopic eczema, measures to maintain the skin and reduce the risk of flares, self-care advice, and information on treatments not recommended. See the section on Additional information and advice for more information.
  • Optimal follow up depends on a number of factors, such as the severity of the condition, the treatment the person is receiving, and their health and age (for instance, more frequent follow up will be needed in a small child receiving large quantities of moderately potent topical corticosteroids).
    • Review emollient use on an annual basis to ensure optimal usage.
    • Topical corticosteroids require regular review if there is heavy usage; however, this is unlikely to be necessary with moderate eczema. Review maintenance therapy with topical corticosteroids at 3–6 months to assess effectiveness.
    • Review the use of non-sedating antihistamines every 3 months (treatment can be stopped, then restarted if symptoms worsen).
  • Refer for a routine dermatology appointment if:
    • The diagnosis is, or has become, uncertain.
    • Current management has not controlled eczema satisfactorily (for example the person is having one to two flares per month), or the person is reacting adversely to many emollients.
    • Facial eczema has not responded to appropriate treatment.
    • Treatment (application) advice is needed (for example bandaging techniques).
    • Contact allergic dermatitis is suspected (for example if there is persistent eczema or facial, eyelid, or hand eczema). See the CKS topic on Dermatitis - contact for more information.
    • There is recurrent secondary infection.
    • Eczema is assessed as causing significant social or psychological problems (for example sleep disturbance).
  • Refer to immunology, dermatology, or paediatrics if a food allergy is suspected and the expertise to diagnose and manage food allergy is not available in primary care. See the section on Breastfed and bottle-fed infants for more information.
  • Refer to a clinical psychologist, people whose eczema is controlled but whose quality of life and psychological well-being have not improved (this may not be directly related to the severity of the eczema).

Basis for recommendation

These recommendations are largely based on expert opinion in the National Institute for Health and Care Excellence (NICE) guideline Atopic eczema in under 12s: diagnosis and management [NICE, 2007a]. NICE reviewed this guideline in July 2016 and found no new evidence to warrant a change in recommendations. CKS has extrapolated the recommendations to include the management of older children and adults.

These recommendations are also in line with those in Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011], Caring for children and young people with atopic eczema: guidance for nurses published by the Royal College of Nursing (RCN) [RCN, 2013], Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies published by the American Academy of Dermatology (AAD) [Eichenfield, 2014b], Atopic eczema published by the Primary Care Dermatology Society (PCDS) [Primary Care Dermatology Society, 2016], the S2k guideline on diagnosis and treatment of atopic dermatitis - short version (a German guideline supported financially by the German Dermatology Society [DDG]) [Werfel, 2016], the ETFAD/EADV Eczema task force 2015 position paper on diagnosis and treatment of atopic dermatitis in adult and paediatric patients published by the European Task Force on Atopic Dermatitis (ETFAD) and European Academy of Dermatology and Venerology (EADV) [Wollenberg, 2016], European Dermatology Forum 2018 guidelines for the treatment of atopic eczema (atopic dermatitis) [Wollenberg, 2018], Japanese guidelines for atopic dermatitis published in 2020 [Katoh, 2020], Malaysian Health Technology Assessment Section 2018 guidelines on the management of atopic eczema , and in review articles on atopic eczema [Baron et al, 2012; Arkwright, 2013; Eichenfield, 2015; Lyons, 2015; Ng, 2015; Stein, 2016; Strathie, 2016; BMJ Best Practice, 2022].

Immediate admission
  • Eczema herpeticum is a potentially life-threatening condition [NICE, 2007a]. If suspected, prompt emergency admission should be arranged for confirmation of the diagnosis and antiviral treatment [NICE, 2007a; Strathie, 2016; MaHTAS, 2018].
Prescribing appropriate treatment
  • NICE recommends a stepped approach for managing atopic eczema. This means that treatment should be tailored to the severity of the eczema, and stepped up or down according to the severity of symptoms [NICE, 2007a].
  • Emollients are almost universally recommended as first-line treatment for atopic eczema, and experts advise that is should form the basis of management and should always be used, even when the skin is clear [NICE, 2007a; SIGN, 2011; Baron et al, 2012; RCN, 2013; Eichenfield, 2014b; Eichenfield, 2015; Lyons, 2015; Ng, 2015; BMJ, 2016; Primary Care Dermatology Society, 2016; Strathie, 2016; Wollenberg, 2016].
    • A Cochrane systematic review of 77 studies (n = 6603, mean age = 18.6 years, mean duration = 6.7 weeks) assessed the effects of moisturisers for eczema [van Zuuren, 2017].   
      • The evidence suggested that most moisturisers showed some beneficial effects in prolonging time to flare, reducing the number of flares, and reducing the amount of topical corticosteroids needed to achieve similar reductions in eczema severity, producing better results when used with active treatment. However, there was no evidence that one moisturiser is better than another. 
      • Adverse events reporting was limited (smarting, stinging, pruritus, erythema, and folliculitis).
  • Topical corticosteroids are the most effective treatment to address the inflammatory component of atopic eczema [Eichenfield, 2014b; Lyons, 2015; Primary Care Dermatology Society, 2016; Wollenberg, 2016], and there is reasonable evidence of benefit for their use [Nankervis, 2016].
    • The potency of the topical steroid should be tailored to the severity of the eczema, and patient specific factors such as age and the area of the skin being treated [NICE, 2007a; Lyons, 2015; Wollenberg, 2018].
    • It is recommended that topical corticosteroids for atopic eczema should be prescribed for application only once or twice daily [NICE, 2004a].
    • Healthcare professionals should discuss the benefits and harms of treatment with topical corticosteroids with people with atopic eczema, and their parents or carers, emphasising that the benefits outweigh possible harms when they are applied correctly.[NICE, 2007a].
    • Several guidelines recommend the use of mild potency corticosteroids for the face and neck [NICE, 2007a; Wollenberg, 2018; SGUH, 2017], with short-term (3 to 5 days) use of moderate potency corticosteroids considered for severe flares [NICE, 2007a; SGUH, 2017]. Moderate or potent preparations should only be used for short periods (7 to 14 days) to treat flares in vulnerable sites such as axillae and groin [NICE, 2007a; SGUH, 2017].
  • Antihistamines are not recommended for routine use in the management of atopic eczema, as they have shown poor efficacy in controlling atopic eczema-associated itch [RCN, 2013; Lyons, 2015; Primary Care Dermatology Society, 2016; Strathie, 2016; Werfel, 2016; Matterne, 2019]. However:
    • NICE recommends that a 1-month trial of a non-sedating antihistamine can be considered where there is severe itching or urticaria. If successful, the treatment can be continued, while symptoms persist, and should be reviewed every 3 months [NICE, 2007a]. 
    • This recommendation is based mainly on clinical experience, as there is only very limited evidence from controlled trials on the effectiveness of antihistamines for the treatment of atopic eczema [Hoare et al, 2000].
Prescribing preventative treatment
  • Topical corticosteroids should ideally be used only during flares of eczema. However, CKS recognizes that some people will require long-term management with a corticosteroid to control their condition.
    • The step down approach is not specifically recommended by NICE for the control of flares, but is implied in their clinical guideline [NICE, 2007a]. This requires the person to use the lowest amount and potency of corticosteroid to control eczema, in an attempt to minimize adverse effects. 
    • The intermittent treatment consists of two treatment options:
      • The twice weekly therapy is recommended in the SIGN guideline, which states that although constant use of topical corticosteroids is undesirable due to the risk of local and systemic adverse effects, twice weekly maintenance treatment with a topical corticosteroid should be considered in people with moderate to severe atopic eczema experiencing frequent relapses [SIGN, 2011].
      • The weekend therapy is recommended by NICE and may prevent flares occurring. There is good evidence from randomized controlled trials (RCTs) that intermittent treatment with a topical corticosteroid (on 2 or 3 consecutive days) can reduce flare recurrence [NICE, 2007a].
    • Expert opinion in a guideline is that the proactive, intermittent use of topical steroids as maintenance treatment (once or twice a week) on areas that commonly flare is useful to help prevent relapses [Eichenfield, 2014b].
  • Tacrolimus and pimecrolimus (topical calcineurin inhibitors) have been shown to be effective in the treatment of atopic eczema [Nankervis, 2016]. Following a Technology Appraisal on their use for atopic eczema, NICE concluded that they [NICE, 2004b]:
    • Are not recommended as first-line treatments for atopic eczema of any severity.
    • Should be initiated 'only by physicians (including general practitioners) with a special interest and experience in dermatology, and only after careful discussion with the person about the potential risks and benefits of all appropriate second-line treatment options'.
Giving appropriate information and advice
Active follow up not required
  • Expert opinion in the PCDS guideline is that a follow-up appointment is a good opportunity to reinforce the continued need to practise good skin care, in particular to encourage the frequent and liberal use of emollients and to ensure that the treatment is suitable for the person [Primary Care Dermatology Society, 2016]. The NICE Guideline Development Group (GDG) states that the repeat prescribing of emollients over long periods without review should be discouraged, and annual reviews should be carried out [NICE, 2007a].
    • NICE does not make any recommendations on the optimal time for review of people using topical corticosteroids, but recommends that people should be referred if they are not responding adequately to treatment with topical corticosteroids [NICE, 2007a].
    • NICE states that the weekend therapy should be reviewed within 3–6 months to assess effectiveness [NICE, 2007a]. CKS has extrapolated this recommendation to the step down and the twice weekly regimens.
Referral
  • The NICE GDG could not find any clinical evidence or evidence on cost-effectiveness in relation to referral and treatment outcomes for eczema. The GDG therefore based these recommendations on referral advice from other guidance and on the GDG's collective experience.
  • Expert opinion in the NICE guideline Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community settings [NICE, 2011b] is that if a food allergy is suspected, a healthcare professional with the appropriate competencies should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person. Management will depend on the results of this. For more information, see the full NICE guideline. 

What information and self-care advice on eczema should I give?

  • Provide information on atopic eczema.
    • Explain that eczema is a chronic illness characterized by flares, which can usually be controlled with appropriate treatment.
    • Also discuss that poorly managed atopic eczema can have a significant impact on psychosocial well-being.
    • Provide information on recognizing:
      • The early or prodromal signs and symptoms of a flare. Should this occur, advise immediate and aggressive treatment using an agreed stepped-care plan.
      • The symptoms and signs of eczema herpeticum, which is a medical emergency.
      • The symptoms and signs of infected eczema. 
    • In children, inform parents/carers that:
      • Eczema often improves with time. However, not all children will grow out of it, and it may get worse in teenage or adult life.
      • Children with atopic eczema can often develop asthma and/or allergic rhinitis and that sometimes food allergy is associated with atopic eczema, especially in very young children.
  • Provide instructions on the correct use of emollients, with clear demonstrations where appropriate. Also address any concerns regarding adverse effects of topical corticosteroids.
  • Give advice on measures to maintain the skin and reduce the risk of flares.
    • Encourage the frequent and liberal use of emollients, even during periods where the skin is clear.
      • Through decreasing symptoms of dryness, pain and itching, emollient use may also lead to a decreased exposure to bacteria and sensitising antigens.
      • Regular use of emollient therapy has been shown to have both short and long-term steroid sparing effects in mild to moderate atopic eczema.
    • Advise that where possible, they should avoid trigger factors known to exacerbate eczema, such as certain clothing (they should avoid wearing synthetic fibres), soaps or detergents (they should use emollient substitutes), animals, and heat (they should keep rooms cool).
      • House-dust mite avoidance strategies are generally not recommended as they are time consuming and of limited benefit.
    • Advise that they should avoid scratching the eczema (if possible), and simply rub the area with their fingers to alleviate itch. Nails should be kept short, and anti-scratch mittens should be used in babies with eczema.
  • Also advise the person and/or their parents/carer that:
    • They should not alter their diet unless under specialist advice.
      • The mothers of breastfed infants in whom allergy is suspected to be the cause of moderate or severe eczema may require referral for dietary advice. 
      • Breastfeeding mothers of children with atopic eczema should not alter their diets unless under specialist advice.
      • See the section on Breastfed and bottle-fed infants for more information.
    • Complementary therapies are not recommended for the management of atopic eczema; a healthcare professional should be informed if these are used. Also advise that:
      • Treatments such as homeopathic remedies, herbal medicine, massage, and food supplements (such as evening primrose oil) have not been adequately assessed in clinical trials.
      • All therapies that claim effectiveness (including natural remedies) may also have adverse effects.
      • Chinese herbal medicines have been associated with life-threatening adverse effects and have in some cases been contaminated with corticosteroids.
      • If they insists on using complementary therapies, they should continue using the emollients frequently and liberally, even when the skin is clear.
  • Support effective self-management of atopic eczema by addressing beliefs and concerns about treatments. These may include:
    • Seeking positive ways to promote a 'control not cure' approach to management.
    • Acknowledging the psychosocial impacts of atopic eczema and the burden of treatment.
    • Providing clear consistent advice or signposting towards reliable information about medicines and management of atopic eczema.
    • Informing people with atopic eczema, and/or their parents or carers, that the condition may temporarily affect skin pigmentation (causing the skin to become lighter or darker).
  • Provide patient information leaflets and information on eczema support groups.

Breastfed and bottle-fed infants

  • The mothers of breastfed infants in whom allergy is suspected to be the cause of moderate or severe eczema may require referral for dietary advice.
    • An allergen-specific exclusion diet may be considered; if this is not possible, the infant may be switched to a specialist formula milk (for example hypoallergenic hydrolyzed or amino acid-based products).
    • A 6–8 week trial of hydrolyzed protein formula milk or amino acid formula milk may be tried in bottle-fed children younger than 6 months of age with eczema that is not controlled by emollients and mild topical corticosteroids.
      • Children who respond well to a change in their milk formula will require referral to a dietitian for further dietary advice to ensure healthy growth and development.
      • Children who do not respond are less likely to have a cow's milk allergy and should restart cow's milk, with monitoring of their eczema.
    • Goat's milk and sheep's milk should not be used as they are nutritionally inadequate for human growth. Goat's milk, in any case, shares 95% of cross-reacting allergens with cows' milk.
    • Partially hydrolyzed formula milks are not suitable as the incomplete hydrolyzation process may be inadequate to completely eliminate all allergens.
      • Soya protein diets can be used in children 6 months of age and older, following specialist advice. Such diets require careful balancing of nutritional content, and children who consume a soya based diet may be more likely to develop a peanut allergy.
    • Advice should be sought from a dietitian with appropriate competencies.
  • See the CKS topic on Cows' milk protein allergy in children for detailed information on this condition.
  • Topical corticosteroids and other topical preparations used to treat atopic eczema are considered suitable to use during breastfeeding.

[NICE, 2007b; NICE, 2011b; SPS, 2019]

Basis for recommendation

These recommendations are largely based on expert opinion in the National Institute for Health and Care Excellence (NICE) guideline Atopic eczema in under 12s: diagnosis and management [NICE, 2007a]. NICE reviewed this guideline in March 2021 and found no new evidence to warrant a change in recommendations. CKS has extrapolated the recommendations to include the management of older children and adults.

These recommendations are also in line with those in Caring for children and young people with atopic eczema: guidance for nurses published by the Royal College of Nursing (RCN) [RCN, 2013], Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies published by the American Academy of Dermatology (AAD) [Eichenfield, 2014b], Atopic eczema published by the Primary Care Dermatology Society (PCDS) [Primary Care Dermatology Society, 2016], S2k guideline on diagnosis and treatment of atopic dermatitis - short version (a German guideline supported financially by the German Dermatology Society [DDG]) [Werfel, 2016], the ETFAD/EADV Eczema task force 2015 position paper on diagnosis and treatment of atopic dermatitis in adult and paediatric patients published by the European Task Force on Atopic Dermatitis (ETFAD) and European Academy of Dermatology and Venerology (EADV)[Wollenberg, 2016], European Dermatology Forum 2018 guidelines for the treatment of atopic eczema (atopic dermatitis) [Wollenberg, 2018], Japanese guidelines for atopic dermatitis published in 2020 [Katoh, 2020], Malaysian Health Technology Assessment Section 2018 guidelines on the management of atopic eczema [MaHTAS, 2018], and in review articles on atopic eczema [Buddenkotte et al, 2010; Baron et al, 2012; Arkwright, 2013; Eichenfield, 2015; Lyons, 2015; Ng, 2015]  [Strathie, 2016]   [BMJ Best Practice, 2022].

Providing information on atopic eczema
Advice on measures to maintain the skin and reduce flares
  • Emollients are the first-line treatments for both acute flares of eczema and during remission [RCN, 2013; Eichenfield, 2014b; Ng, 2015; Primary Care Dermatology Society, 2016; Wollenberg, 2018; MaHTAS, 2018].
  • NICE states that treating dry skin (an early sign of a flare) with an emollient may prevent the flare worsening [NICE, 2007a].
    • Scratching is thought to be a major component of flare progression, as it physically damages the skin and can delay healing or facilitate infection. Emollients are believed to ease itching and thus may have a role in breaking the itch-scratch cycle [Grimalt et al, 2007; Wollenberg, 2018].
  • A Cochrane systematic review of 77 studies (n = 6603, mean age = 18.6 years, mean duration = 6.7 weeks) assessed the effects of moisturisers for eczema [van Zuuren, 2017]. The evidence suggested that most moisturisers showed some beneficial effects in prolonging time to flare, reducing the number of flares, and reducing the amount of topical corticosteroids needed to achieve similar reductions in eczema severity, producing better results when used with active treatment. However, there was no evidence that one moisturiser is better than another. 
Advice on avoiding triggers
  • Avoiding scratching — the benefit of the short-term relief by scratching the skin is counteracted by a simultaneous damage of the epidermis, leading to increased transepidermal water loss and drying, which in turn results in a cycle of more itching and more scratching [Buddenkotte et al, 2010].
  • House-dust mite avoidance — NICE does not recommend house-dust mite elimination strategies for managing atopic eczema [NICE, 2007a]. Although people with atopic eczema are often sensitized to house dust mites [Eichenfield, 2014a], there is no strong evidence that dust mite avoidance strategies are effective in treating or preventing atopic eczema:
    • A systematic review and meta-analysis (n = 3040) assessed dust mite avoidance measures for the primary prevention of atopic dermatitis and found that they provided no benefit in the prevention of atopic dermatitis [Bremmer, 2015].
    • A Cochrane systematic review (search date: August 2014) assessed the effects of house dust mite reduction and avoidance measures for the treatment of atopic eczema and was unable to determine clear implications to inform clinical practice, due to the low-quality evidence available [Nankervis, 2015].
  • Irritants, temperature, humidity, pet removal, and stress — NICE found no evidence regarding avoidance of these triggers. However, experts recommend that if these triggers exacerbate eczema, they should be avoided, where possible [RCN, 2013; BAD, 2017].
  • Dietary modification:
    • Evidence from a Cochrane systematic review (search date: March 2006) suggests that there is no benefit from milk and egg-free exclusion diets in people who do not have a known allergy to specific foods [Bath-Hextall, 2008b].
    • Expert opinion in the NICE guideline Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community settings [NICE, 2011b] is that if a food allergy is suspected, a healthcare professional with the appropriate competencies should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person. For more information, see the full NICE guideline.
    • Expert opinion in guidelines [RCN, 2013; Werfel, 2016; Wollenberg, 2018] and review articles [Lyons, 2015; Strathie, 2016] on atopic eczema is that any dietary exclusion or elimination diets should be implemented and monitored by a specialist.
    • There is limited evidence to recommend the use of few-food diets, elemental diets, probiotic supplements, sodium cromoglicate, dietary exclusion in breastfeeding women [NICE, 2007b; Lloyd-Lavery, 2016], or dietary supplements with zinc, essential fatty acids, or vitamin B6 [BMJ Best Practice, 2022] for the management of atopic eczema.
Treatments not recommended
  • There is insufficient evidence to recommend complementary therapies (homeopathy, herbal medicine, massage, and food supplements) in the management of atopic eczema [RCN, 2013; NICE, 2007b; Nankervis, 2016; Wollenberg, 2018; Lu, 2018].
  • Limited evidence identified by CKS does not support the use of Chinese herbal medicine [Gu, 2013], oral evening primrose oil [Bamford, 2013], or borage oil [Bamford, 2013] for the management of atopic eczema. 
  • The Medicines and Healthcare products Regulatory Agency (MHRA) warns that the phrases 'natural', 'herbal', and 'derived from plants' do not necessarily mean that the product is 'safe'. Herbal medicines, like other medicines, can have adverse effects. They can also interact with other medicines, resulting in reduced or enhanced effects of the other medicines. For further information, see www.mhra.gov.uk/safetyinformation [MHRA, 2012].

Regular use of emollient therapy has been shown to have both short and long-term steroid sparing effects in mild to moderate atopic eczema

  • Recommendation provided in consensus-based European guidelines for the treatment of atopic eczema [Wollenberg, 2016].

Effective self-management of atopic eczema can be supported by addressing beliefs and concerns about treatments

  • Findings from a systematic review and thematic synthesis of qualitative studies which assessed the views and experiences of individuals managing atopic eczema form the basis of these recommendations [Teasdale, 2021].

Scenario: Severe eczema

From age 1 month onwards.

How should I manage severe eczema?

If a person presents with severe eczema (or an acute flare of severe eczema):

  • Consider the need for immediate admission or referral. For example:
    • Admit to hospital if eczema herpeticum (widespread herpes simplex virus) is suspected.
  • Consider the possibility of trigger factors or infection, which can precipitate or worsen a flare.
  • Prescribe appropriate treatment.
    • Prescribe a generous amount of emollients and advise frequent and liberal use (more than usual). For more information on emollients, including available products and usage instructions, see the prescribing information section on Emollients.
    • If the skin is inflamed, prescribe a potent topical corticosteroid (for example betamethasone valerate 0.1%) to be used on inflamed areas.
      • For delicate areas of skin such as the face and flexures, use a moderate potency corticosteroid (such as betamethasone valerate 0.025% or clobetasone butyrate 0.05%). Aim for a maximum of 5 days' use.
      • Do not use potent corticosteroids in children under 12 months old, or very potent corticosteroids in children of any age, without specialist dermatological advice.
      • For more information on topical corticosteroids, including available products and usage instructions, see the prescribing information section on Topical corticosteroids.
    • Occlusive dressings or dry bandages may be of benefit; however, treatment should only be started by a healthcare professional trained in their use (otherwise consider referral).
    • If there is severe itch or urticaria, consider prescribing a one-month trial of a non-sedating antihistamine (such as cetirizine, loratadine, or fexofenadine). 
    • If itching is severe and affecting sleep, consider prescribing a short course (maximum of two weeks) of a sedating antihistamine (such as chlorphenamine). For more information see the CKS topic on Insomnia. 
    • If there is severe, extensive eczema causing psychological distress, consider prescribing a short course of an oral corticosteroid (refer children under 16 years of age). There are no data from controlled trials, but 30 mg prednisolone taken in the morning for 1 week should be sufficient.
    • If there are signs of infection, see Scenario: Infected eczema for management information.
  • Prescribe preventative treatment according to the usual severity of the condition between flares.
    • Consider prescribing a maintenance regimen of topical corticosteroids to control areas of skin prone to frequent flares (not recommended for the face, genitals, or axillae). Options include a 'step down approach' or 'intermittent treatment'. See the section on Maintenance regimens for more information on this regimens.
    • Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are a second-line option. However, they should only be prescribed by a specialist (including GPs with a specialist interest in dermatology).
  • Give appropriate information and advice, including general information on atopic eczema, measures to maintain the skin and reduce the risk of flares, self-care advice, and information on treatments not recommended. See the section on Additional information and advice for more information.
  • Optimal follow up depends on a number of factors, such as the severity of the condition, the treatment the person is receiving, and their health and age (for instance, more frequent follow up will be needed in a small child receiving large amounts of moderately potent topical corticosteroids).
    • Review emollient use on an annual basis to ensure optimal usage.
    • Topical corticosteroids require regular review if there is heavy usage. Review maintenance therapy with topical corticosteroids at 3–6 months to assess effectiveness.
    • Review the use of non-sedating antihistamines every 3 months (treatment can be stopped, then restarted if symptoms worsen).
    • For all people who have had a severe and extensive flare requiring treatment with oral corticosteroids or oral antibiotics, review after the course has finished, and consider the need for referral.
  • Refer urgently (within 2 weeks) to dermatology if eczema is severe and has not responded to optimum topical treatment after 1 week.
  • Refer for a routine dermatology appointment if:
    • The diagnosis is, or has become, uncertain.
    • Current management has not controlled eczema satisfactorily (for example the person is having one to two flares per month), or the person is reacting adversely to many emollients.
    • Facial eczema has not responded to appropriate treatment.
    • Treatment (application) advice is needed (for example bandaging techniques).
    • Contact allergic dermatitis is suspected (for example if there is persistent eczema or facial, eyelid, or hand eczema). See the CKS topic on Dermatitis - contact for more information.
    • There is recurrent secondary infection.
    • Eczema is assessed as causing significant social or psychological problems (for example sleep disturbance).
  • Refer to immunology, dermatology, or paediatrics if a food allergy is suspected and the expertise to diagnose and manage food allergy is not available in primary care. See the section on Breastfed and bottle-fed infants for more information.
  • Refer to a clinical psychologist, people whose eczema is controlled, but whose quality of life and psychological well-being have not improved (this may not be directly related to the severity of the eczema).

Basis for recommendation

These recommendations are largely based on expert opinion in the National Institute for Health and Care Excellence (NICE) guideline Atopic eczema in under 12s: diagnosis and management [NICE, 2007a]. NICE reviewed this guideline in July 2016 and found no new evidence to warrant a change in recommendations. CKS has extrapolated the recommendations to include the management of older children and adults.

These recommendations are also in line with those in Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011], Caring for children and young people with atopic eczema: guidance for nurses published by the Royal College of Nursing (RCN) [RCN, 2013], Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies published by the American Academy of Dermatology (AAD) [Eichenfield, 2014b], Atopic eczema published by the Primary Care Dermatology Society (PCDS) [Primary Care Dermatology Society, 2016], the S2k guideline on diagnosis and treatment of atopic dermatitis - short version (a German guideline supported financially by the German Dermatology Society [DDG]) [Werfel, 2016], the ETFAD/EADV Eczema task force 2015 position paper on diagnosis and treatment of atopic dermatitis in adult and paediatric patients published by the European Task Force on Atopic Dermatitis (ETFAD) and European Academy of Dermatology and Venerology (EADV) [Wollenberg, 2016], European Dermatology Forum 2018 guidelines for the treatment of atopic eczema (atopic dermatitis) [Wollenberg, 2018], Japanese guidelines for atopic dermatitis published in 2020 [Katoh, 2020], Malaysian Health Technology Assessment Section 2018 guidelines on the management of atopic eczema , and in review articles on atopic eczema [Baron et al, 2012; Arkwright, 2013; Eichenfield, 2015; Lyons, 2015; Ng, 2015; Stein, 2016; Strathie, 2016; BMJ Best Practice, 2022].

Immediate admission
Prescribing appropriate treatment
  • NICE recommends a stepped approach for managing atopic eczema. This means that treatment should be tailored to the severity of the eczema, and stepped up or down according to the severity of symptoms [NICE, 2007a].
  • Emollients are almost universally recommended as first-line treatment for atopic eczema, and experts advise that is should form the basis of management and should always be used, even when the skin is clear [NICE, 2007a; SIGN, 2011; Baron et al, 2012; RCN, 2013; Eichenfield, 2014b; Eichenfield, 2015; Lyons, 2015; Ng, 2015; BMJ, 2016; Primary Care Dermatology Society, 2016; Strathie, 2016; Wollenberg, 2016].
    • A Cochrane systematic review of 77 studies (n = 6603, mean age = 18.6 years, mean duration = 6.7 weeks) assessed the effects of moisturisers for eczema [van Zuuren, 2017].
      • The evidence suggested that most moisturisers showed some beneficial effects in prolonging time to flare, reducing the number of flares, and reducing the amount of topical corticosteroids needed to achieve similar reductions in eczema severity, producing better results when used with active treatment. However, there was no evidence that one moisturiser is better than another. 
      • Adverse events reporting was limited (smarting, stinging, pruritus, erythema, and folliculitis).
  • Topical corticosteroids are the most effective treatment to address the inflammatory component of atopic eczema [Eichenfield, 2014b; Lyons, 2015; Primary Care Dermatology Society, 2016; Wollenberg, 2016], and there is reasonable evidence of benefit for their use [Nankervis, 2016].
    • The potency of the topical steroid should be tailored to the severity of the eczema, and patient specific factors such as age and the area of the skin being treated [NICE, 2007a; Lyons, 2015; Wollenberg, 2018].
    • It is recommended that topical corticosteroids for atopic eczema should be prescribed for application only once or twice daily [NICE, 2004a].
    • Healthcare professionals should discuss the benefits and harms of treatment with topical corticosteroids with people with atopic eczema, and their parents or carers, emphasising that the benefits outweigh possible harms when they are applied correctly.[NICE, 2007a].
    • Several guidelines recommend the use of mild potency corticosteroids for the face and neck [NICE, 2007a; Wollenberg, 2018; SGUH, 2017], with short-term (3 to 5 days) use of moderate potency corticosteroids considered for severe flares [NICE, 2007a; SGUH, 2017]. Moderate or potent preparations should only be used for short periods (7 to 14 days) to treat flares in vulnerable sites such as axillae and groin [NICE, 2007a; SGUH, 2017].
  • Antihistamines are not recommended for routine use in the management of atopic eczema, as they have shown poor efficacy in controlling atopic eczema-associated itch [RCN, 2013; Lyons, 2015; Primary Care Dermatology Society, 2016; Strathie, 2016; Werfel, 2016; Matterne, 2019]. However:
    • NICE recommends that a 1-month trial of a non-sedating antihistamine can be considered where there is severe itching or urticaria. If successful, the treatment can be continued, while symptoms persist, and should be reviewed every 3 months [NICE, 2007a]. 
    • This recommendation is based mainly on clinical experience, as there is only very limited evidence from controlled trials on the effectiveness of antihistamines for the treatment of atopic eczema [Hoare et al, 2000].
  • Oral corticosteroids should be reserved for use in the treatment of severe flares, often while waiting for referral to secondary care where the condition can be fully assessed and other treatment options can be tried [Drucker, 2018]. There is no evidence from controlled trials to support the effectiveness of oral corticosteroids, but clinical experience suggests that there is a large and rapid treatment effect. Prolonged or frequent treatment should be avoided as there is a cumulative risk of serious adverse effects [Schmitt et al, 2007; Drucker, 2018; Wollenberg, 2018].
Prescribing preventative treatment
  • Topical corticosteroids should ideally be used only during flares of eczema. However, CKS recognizes that some people will require long-term management with a corticosteroid to control their condition.
    • The step down approach is not specifically recommended by NICE for the control of flares, but is implied in their clinical guideline [NICE, 2007a]. This requires the person to use the lowest amount and potency of corticosteroid to control eczema, in an attempt to minimize adverse effects. 
    • The intermittent treatment consists of two treatment options:
      • The twice weekly therapy is recommended in the SIGN guideline, which states that although constant use of topical corticosteroids is undesirable due to the risk of local and systemic adverse effects, twice weekly maintenance treatment with a topical corticosteroid should be considered in people with moderate to severe atopic eczema experiencing frequent relapses [SIGN, 2011].
      • The weekend therapy is recommended by NICE and may prevent flares occurring. There is good evidence from randomized controlled trials (RCTs) that intermittent treatment with a topical corticosteroid (on 2 or 3 consecutive days) can reduce flare recurrence [NICE, 2007a].
    • Expert opinion in a guideline is that the proactive, intermittent use of topical steroids as maintenance treatment (once or twice a week) on areas that commonly flare is useful to help prevent relapses [Eichenfield, 2014b].
  • Tacrolimus and pimecrolimus (topical calcineurin inhibitors) have been shown to be effective in the treatment of atopic eczema [Nankervis, 2016]. Following a Technology Appraisal on their use for atopic eczema, NICE concluded that they [NICE, 2004b]:
    • Are not recommended as first-line treatments for atopic eczema of any severity.
    • Should be initiated 'only by physicians (including general practitioners) with a special interest and experience in dermatology, and only after careful discussion with the person about the potential risks and benefits of all appropriate second-line treatment options'.
Giving appropriate information and advice
Active follow up not required
  • Expert opinion in the PCDS guideline is that a follow-up appointment is a good opportunity to reinforce the continued need to practise good skin care, in particular to encourage the frequent and liberal use of emollients and to ensure that the treatment is suitable for the person [Primary Care Dermatology Society, 2016]. The NICE Guideline Development Group (GDG) states that the repeat prescribing of emollients over long periods without review should be discouraged, and annual reviews should be carried out [NICE, 2007a].
    • NICE does not make any recommendations on the optimal time for review of people using topical corticosteroids, but recommends that people should be referred if they are not responding adequately to treatment with topical corticosteroids [NICE, 2007a].
    • NICE states that the weekend therapy should be reviewed within 3–6 months to assess effectiveness [NICE, 2007a]. CKS has extrapolated this recommendation to the step down and the twice weekly regimens.
    • NICE also recommends that people who have received systemic treatment for eczema or infection require a review to ensure treatment has been successful (if not, referral is required) [NICE, 2007a].
Referral
  • The NICE GDG could not find any clinical evidence or evidence on cost-effectiveness in relation to referral and treatment outcomes for eczema. The GDG therefore based these recommendations on referral advice from other guidance and on the GDG's collective experience.
  • Expert opinion in the NICE guideline Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community settings [NICE, 2011b] is that if a food allergy is suspected, a healthcare professional with the appropriate competencies should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person. Management will depend on the results of this. For more information, see the full NICE guideline. 

What information and self-care advice should I give about eczema?

  • Provide information on atopic eczema.
    • Explain that eczema is a chronic illness characterized by flares, which can usually be controlled with appropriate treatment.
    • Provide information on recognizing:
      • The early or prodromal signs and symptoms of a flare. Should this occur, advise immediate and aggressive treatment using an agreed stepped-care plan.
      • The symptoms and signs of eczema herpeticum, which is a medical emergency.
      • The symptoms and signs of infected eczema. 
    • In children, inform parents/carers that:
      • Eczema often improves with time. However, not all children will grow out of it, and it may get worse in teenage or adult life.
      • Children with atopic eczema can often develop asthma and/or allergic rhinitis and that sometimes food allergy is associated with atopic eczema, especially in very young children.
  • Provide instructions on the correct use of emollients, with clear demonstrations where appropriate. Also address any concerns regarding adverse effects of topical corticosteroids.
  • Give advice on measures to maintain the skin and reduce the risk of flares.
    • Encourage the frequent and liberal use of emollients, even during periods where the skin is clear.
    • Advise that where possible, they should avoid trigger factors known to exacerbate eczema, such as certain clothing (they should avoid wearing synthetic fibres), soaps or detergents (they should use emollient substitutes), animals, and heat (they should keep rooms cool).
      • House-dust mite avoidance strategies are generally not recommended as they are time consuming and of limited benefit.
    • Advise that they should avoid scratching the eczema (if possible), and simply rub the area with their fingers to alleviate itch. Nails should be kept short, and anti-scratch mittens should be used in babies with eczema.
  • Also advise the person and/or their parents/carer that:
    • They should not alter their diet unless under specialist advice.
      • The mothers of breastfed infants in whom allergy is suspected to be the cause of moderate or severe eczema may require referral for dietary advice.
      • Breastfeeding mothers of children with atopic eczema should not alter their diets unless under specialist advice.
      • See the section on Breastfed and bottle-fed infants for more information.
    • Complementary therapies are not recommended for the management of atopic eczema; a healthcare professional should be informed if these are used. Also advise that:
      • Treatments such as homeopathy, herbal medicine, massage, and food supplements (such as evening primrose oil) have not been adequately assessed in clinical trials.
      • All therapies that claim effectiveness (including natural remedies) may also have adverse effects.
      • Chinese herbal medicines have been associated with life-threatening adverse effects and have in some cases been contaminated with corticosteroids.
      • If they insist on using complementary therapies, they should continue using the emollients frequently and liberally, even when the skin is clear.
  • Provide patient information leaflets and information on eczema support groups.

Breastfed and bottle-fed infants:

  • The mothers of breastfed infants in whom allergy is suspected to be the cause of moderate or severe eczema may require referral for dietary advice.
    • An allergen-specific exclusion diet may be considered; if this is not possible, the infant may be switched to a specialist formula milk (for example hypoallergenic hydrolyzed or amino acid-based products).
    • A 6–8 week trial of hydrolyzed protein formula milk or amino acid formula milk may be tried in bottle-fed children younger than 6 months of age with eczema that is not controlled by emollients and mild topical corticosteroids.
      • Children who do not respond are less likely to have a cows' milk allergy and should restart cow's milk, with monitoring of their eczema.
      • Children who respond well to a change in their milk formula will require referral to a dietitian for further dietary advice to ensure healthy growth and development.
      • Goat's milk and sheep's milk should not be used as they are nutritionally inadequate for human growth. Goat's milk, in any case, shares 95% of cross-reacting allergens with cows' milk.
      • Partially hydrolyzed formula milks are not suitable as the incomplete hydrolyzation process may be inadequate to completely eliminate all allergens.
        • Soya protein diets can be used in children 6 months of age and older, following specialist advice. Such diets require careful balancing of nutritional content, and children who consume a soya based diet may be more likely to develop a peanut allergy.
      • Advice should be sought from a dietitian with appropriate competencies.
  • See the CKS topic on Cows' milk protein allergy in children for detailed information on this condition.
  • Topical corticosteroids and other topical preparations used to treat atopic eczema are considered suitable to use during breatfeeding.

[NICE, 2007b; NICE, 2011b; SPS, 2019]

Basis for recommendation

These recommendations are largely based on expert opinion in the National Institute for Health and Care Excellence (NICE) guideline Atopic eczema in under 12s: diagnosis and management [NICE, 2007a]. NICE reviewed this guideline in March 2021 and found no new evidence to warrant a change in recommendations. CKS has extrapolated the recommendations to include the management of older children and adults.

These recommendations are also in line with those in Caring for children and young people with atopic eczema: guidance for nurses published by the Royal College of Nursing (RCN) [RCN, 2013], Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies published by the American Academy of Dermatology (AAD) [Eichenfield, 2014b], Atopic eczema published by the Primary Care Dermatology Society (PCDS) [Primary Care Dermatology Society, 2016], S2k guideline on diagnosis and treatment of atopic dermatitis - short version (a German guideline supported financially by the German Dermatology Society [DDG]) [Werfel, 2016], the ETFAD/EADV Eczema task force 2015 position paper on diagnosis and treatment of atopic dermatitis in adult and paediatric patients published by the European Task Force on Atopic Dermatitis (ETFAD) and European Academy of Dermatology and Venerology (EADV) [Wollenberg, 2016], European Dermatology Forum 2018 guidelines for the treatment of atopic eczema (atopic dermatitis) [Wollenberg, 2018], Japanese guidelines for atopic dermatitis published in 2020 [Katoh, 2020], Malaysian Health Technology Assessment Section 2018 guidelines on the management of atopic eczema [MaHTAS, 2018], and in review articles on atopic eczema [Buddenkotte et al, 2010; Baron et al, 2012; Arkwright, 2013; Eichenfield, 2015; Lyons, 2015; Ng, 2015; Strathie, 2016; BMJ Best Practice, 2022].

Providing information on atopic eczema
Advice on measures to maintain the skin and reduce flares
  • Emollients are the first-line treatments for both acute flares of eczema and during remission [RCN, 2013; Eichenfield, 2014b; Ng, 2015; Primary Care Dermatology Society, 2016; Wollenberg, 2018; MaHTAS, 2018].
  • NICE states that treating dry skin (an early sign of a flare) with an emollient may prevent the flare worsening [NICE, 2007a].
    • Scratching is thought to be a major component of flare progression, as it physically damages the skin and can delay healing or facilitate infection. Emollients are believed to ease itching and thus may have a role in breaking the itch-scratch cycle [Grimalt et al, 2007; Wollenberg, 2018].
  • A Cochrane systematic review of 77 studies (n = 6603, mean age = 18.6 years, mean duration = 6.7 weeks) assessed the effects of moisturisers for eczema [van Zuuren, 2017]. The evidence suggested that most moisturisers showed some beneficial effects in prolonging time to flare, reducing the number of flares, and reducing the amount of topical corticosteroids needed to achieve similar reductions in eczema severity, producing better results when used with active treatment. However, there was no evidence that one moisturiser is better than another. 
Advice on avoiding triggers
  • Avoiding scratching — the benefit of the short-term relief by scratching the skin is counteracted by a simultaneous damage of the epidermis, leading to increased transepidermal water loss and drying, which in turn results in a cycle of more itching and more scratching [Buddenkotte et al, 2010].
  • House-dust mite avoidance — NICE does not recommend house-dust mite elimination strategies for managing atopic eczema [NICE, 2007a]. Although people with atopic eczema are often sensitized to house dust mites [Eichenfield, 2014a], there is no strong evidence that dust mite avoidance strategies are effective in treating or preventing atopic eczema:
    • A systematic review and meta-analysis (n = 3040) assessed dust mite avoidance measures for the primary prevention of atopic dermatitis and found that they provided no benefit in the prevention of atopic dermatitis [Bremmer, 2015].
    • A Cochrane systematic review (search date: August 2014) assessed the effects of house dust mite reduction and avoidance measures for the treatment of atopic eczema and was unable to determine clear implications to inform clinical practice, due to the low-quality evidence available [Nankervis, 2015].
  • Irritants, temperature, humidity, pet removal, and stress — NICE found no evidence regarding avoidance of these triggers. However, experts recommend that if these triggers exacerbate eczema, they should be avoided, where possible [RCN, 2013; BAD, 2017].
  • Dietary modification:
    • Evidence from a Cochrane systematic review (search date: March 2006) suggests that there is no benefit from milk and egg-free exclusion diets in people who do not have a known allergy to specific foods [Bath-Hextall, 2008b].
    • Expert opinion in the NICE guideline Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community settings [NICE, 2011b] is that if a food allergy is suspected, a healthcare professional with the appropriate competencies should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person. For more information, see the full NICE guideline.
    • Expert opinion in guidelines [RCN, 2013; Werfel, 2016; Wollenberg, 2018] and review articles [Lyons, 2015; Strathie, 2016] on atopic eczema is that any dietary exclusion or elimination diets should be implemented and monitored by a specialist.
    • There is limited evidence to recommend the use of few-food diets, elemental diets, probiotic supplements, sodium cromoglicate, dietary exclusion in breastfeeding women [NICE, 2007b; Lloyd-Lavery, 2016], or dietary supplements with zinc, essential fatty acids, or vitamin B6 [BMJ Best Practice, 2022] for the management of atopic eczema.
Treatments not recommended
  • There is insufficient evidence to recommend complementary therapies (homeopathy, herbal medicine, massage, and food supplements) in the management of atopic eczema [RCN, 2013; NICE, 2007b; Nankervis, 2016; Wollenberg, 2018; Lu, 2018].
  • Limited evidence identified by CKS does not support the use of Chinese herbal medicine [Gu, 2013], oral evening primrose oil [Bamford, 2013], or borage oil [Bamford, 2013] for the management of atopic eczema. 
  • The Medicines and Healthcare products Regulatory Agency (MHRA) warns that the phrases 'natural', 'herbal', and 'derived from plants' do not necessarily mean that the product is 'safe'. Herbal medicines, like other medicines, can have adverse effects. They can also interact with other medicines, resulting in reduced or enhanced effects of the other medicines. For further information, see www.mhra.gov.uk/safetyinformation [MHRA, 2012].

Regular use of emollient therapy has been shown to have both short and long-term steroid sparing effects in mild to moderate atopic eczema

  • Recommendation provided in consensus-based European guidelines for the treatment of atopic eczema [Wollenberg, 2016].

Effective self-management of atopic eczema can be supported by addressing beliefs and concerns about treatments

  • Findings from a systematic review and thematic synthesis of qualitative studies which assessed the views and experiences of individuals managing atopic eczema form the basis of these recommendations [Teasdale, 2021].

Scenario: Infected eczema

From age 1 month onwards.

How should I manage infected eczema?

  • Consider the need for admission or referral.
    • Admit to hospital if eczema herpeticum (widespread herpes simplex virus) is suspected.
  • Typical signs and symptoms of secondary bacterial infection of eczema can include weeping, pustules, crusts, rapidly worsening eczema, fever and malaise.
  • In people who are not systemically unwell, do not routinely offer either a topical or oral antibiotic for secondary bacterial infection of eczema.
    • Take into account:
      • The limited benefit of antibiotics in addition to topical corticosteroids compared with topical corticosteroids alone.
      • The risk of antimicrobial resistance with repeated courses of antibiotics.
      • The extent and severity of symptoms or signs.
      • The risk of developing complications, which is higher in people with underlying conditions such as immunosuppression.
  • If an antibiotic is offered to people who are not systemically unwell with a secondary bacterial infection of eczema prescribe appropriate treatment.
    • Flucloxacillin is the first-line choice.
    • Prescribe clarithromycin if the person has an allergy to penicillin or if there is known resistance to flucloxacillin. If the person is pregnant and is allergic to penicillin prescribe erythromycin.  
    • If the infection responds poorly to the first-line antibiotic, prescribe an alternative antibiotic, if necessary, and consider sending for a skin swab for microbiological testing, or seek specialist advice.
    • If there are localized areas of infection, consider prescribing topical fusidic acid.
    • For more information on using antibiotics, see the prescribing information sections on Oral antibiotics and Topical antibiotics and antiseptics.
  • Offer treatment and advice to reduce the risk of further infection.
    • Prescribe new supplies of topical products (emollients and corticosteroids) for use after the infection has cleared, and advise the person to discard the old products.
  • For people with secondary bacterial infection of eczema that recurs frequently:
    • Send a skin swab for microbiological testing and
    • Consider taking a nasal swab and starting treatment for decolonization.
  • Episodes of infected eczema usually co-exist with a flare and will require concomitant treatment at the appropriate treatment step. See Scenario: Mild eczema, Scenario: Moderate eczema, or Scenario: Severe eczema for management information.
  • Refer urgently (within 2 weeks) if infected eczema has not responded to treatment.
  • Consider referral or seeking specialist advice if the person is at high risk of complications. 
  • Refer routinely to a dermatology department if:
    • The diagnosis is, or has become, uncertain.
    • Eczema is associated with severe and recurrent infections, especially deep abscesses or pneumonia.

Basis for recommendation

These recommendations are largely based on expert opinion in the National Institute for Health and Care Excellence (NICE) guidelines Atopic eczema in under 12s: diagnosis and management [NICE, 2007a]. NICE reviewed this guideline in March 2021 and found no new evidence to warrant a change in recommendations. CKS has extrapolated these recommendations to include the management of older children and adults. NICE also produced a new guideline in March 2021; Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing NICE, 2021.

These recommendations are also in line with those in Management of atopic eczema in primary care published by the Scottish Intercollegiate Guideline Network (SIGN) [SIGN, 2011], Atopic eczema published by the Primary Care Dermatology Society (PCDS) [Primary Care Dermatology Society, 2016], and in review articles on atopic eczema [Baron et al, 2012; Arkwright, 2013; Tollefson, 2014; Eichenfield, 2015; Lyons, 2015; Strathie, 2016; Totté, 2016; BMJ Best Practice, 2022].

Immediate admission
Prescribing appropriate treatment
  • Choice of antiobiotic formulation
    • NICE advise that a topical rather than an oral antibiotic is more appropriate if the person is not systemically unwell, and the infection is localised and not severe whereas an oral antiobiotic may be more appropriate if the infection is widespread or severe [NICE, 2021].
  • Oral antibiotics
    • Evidence to support the effectiveness of oral antibiotics in the treatment of visibly infected atopic eczema is limited due to a lack of high-quality studies. However, clinical experience indicates that treatment of grossly infected skin is usually warranted [Hoare et al, 2000]. Expert opinion in a review article is that short courses of oral antibiotics are recommended if there is widespread, infected eczema [Strathie, 2016]. 
    • NICE advice from Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing is that the evidence suggests that using topical or oral antibiotics in addition to topical corticosteroids offered little benefit over using topical corticosteroids alone in people with a suspected secondary bacterial infection of eczema in the absence of systemic illness [NICE, 2021].
  • Choice of antibiotic 
    • Flucloxacillin is the drug of choice for the treatment of atopic eczema that is visibly infected [NICE, 2021]. It is a narrow-spectrum beta-lactam antibiotic with good activity against Staphylococcal aureus, which is the most common causative pathogen [Tollefson, 2014; Lyons, 2015; Strathie, 2016; Totté, 2016].
    • A macrolide is a suitable alternative if penicillins are contraindicated.
    • If MRSA infection is suspected, discussion with microbiology experts is required.
  • Topical antibiotics
    • There is a lack of evidence from controlled trials to support the use of topical antibiotics to treat infected atopic eczema, with only one randomized controlled trial investigating this. Data from trials that compared the use of topical antibiotic and corticosteroid combination products have not shown that addition of the antibiotic component provides benefit beyond that of a corticosteroid alone [Hoare et al, 2000].
    • NICE advise that in terms of the choice of topical antibiotics: 'The first-choice topical antibiotic in adults, young people and children with secondary bacterial infection of eczema is fusidic acid 2% (either as a cream or an ointment).
      • The committee discussed that, in the absence of strong evidence, fusidic acid 2% was the most appropriate first choice topical antibiotic because topical mupirocin should be reserved for treating meticillin-resistant S. aureus (MRSA) colonisation'. NICE did not recommend an alternative topical antibiotic for secondary bacterial infection of eczema. This was because, if fusidic acid is unsuitable or ineffective, an oral antibiotic is preferred [NICE, 2021].
  • Swabbing
    • NICE advise that skin swabs for microbiological testing should not routinely be taken at the initial presentation of a suspected secondary bacterial infection of eczema. The skin of people with eczema is often heavily colonized with S. aureus bacteria, and bacterial growth from a skin swab is likely regardless of infection status. Taking skin swabs from everyone with a suspected infection could lead to inappropriate antibiotic prescribing. If the eczema is clinically infected, the most likely causative organisms are S. aureus or Streptococcus pyogenes, so empirical treatment with topical fusidic acid or oral flucloxacillin would be effective [NICE, 2021].
Reducing the risk of further infection
  • These recommendations are based on expert opinion in the NICE guideline [NICE, 2007a] and the SIGN guideline [SIGN, 2011]. 
    • Topical corticosteroids and emollients should be discarded after the infection has cleared, as pathogens can contaminate them and survive in product packaging. This applies particularly to creams packaged in tubs and tubes, although the risk is probably less with pump-dispensers.
    • Encouraging the person to keep their skin in good condition by the appropriate use of emollients and other products, and the avoidance of trigger factors will help reduce the frequency of flares and infection.
Referral

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) or the British National Formulary (BNF).

NICE stepped approach to treatment

  • The stepped approach, recommended by the National Institute for Health and Care Excellence (NICE), for the treatment of atopic eczema is shown in Table 1. Treatment can be stepped up or down according to the severity of the condition. Treatment of a flare will often require temporarily 'upping' the intensity of treatment (for example the strength of corticosteroid).
    • Topical calcineurin inhibitors, phototherapy, and ciclosporin are less suitable for the acute treatment of flares.
    • Bandaging and oral corticosteroids are unsuitable for maintenance treatment.

Table 1. Stepped treatment options for atopic eczema.

Mild atopic eczema

Moderate eczema

Severe eczema

EmollientsEmollientsEmollients
Mild potency topical corticosteroidsModerate potency topical corticosteroidsPotent topical corticosteroids
—Topical calcineurin inhibitors (tacrolimus or pimecrolimus)*Topical calcineurin inhibitors (tacrolimus or pimecrolimus)*
—Bandages*Bandages*
——Phototherapy†
——Oral corticosteroids‡

* Usually only prescribed by a specialist (for example a GP with a specialist interest in dermatology, a dermatologist, or a paediatrician).

† Phototherapy is available in secondary care for the treatment of very severe eczema that has proved resistant to standard treatment. Systemic immunosuppressants (for example ciclosporin and azathioprine) are also available in secondary care for the same indication. 
‡ Oral corticosteroids can be prescribed short-term in primary care for severe flares. Other systemic treatments suitable for maintenance of severe eczema (for example ciclosporin or azathioprine) require referral to secondary care.
Data from: [NICE, 2007a]

Emollients

Which emollient products are available?

  • There are a large number of emollients available in the UK, including creams, ointments, gels, lotions, sprays, washes, and bath and shower additives, available as non-proprietary and/or proprietary products.
    • For a complete list of all the emollient products available in the UK, see the British National Formulary (BNF).
  • Most emollient products are plain (containing no active ingredients).
    • However, some emollients contain:
      • Urea (a keratin softener and hydrating agent), for example Aquadrate®, Balneum® Plus, E45® Itch Relief Cream, Eucerin® Intensive, Hydromol® Intensive and ImuDERM®.
      • Lauromacrogols (which have local anaesthetic properties, and soothes and relieves itchy skin), for example Balneum® Plus and E45® Itch Relief Cream.
      • Lanolin or lanolin derivatives, for example hydrous ointment, E45® cream and lotion, and Oilatum® emollient bath additive.
      • Antiseptic, for example Dermol® preparations (cream, lotion, shower, and bath emollient), Emulsiderm® liquid emulsion, and Oilatum® Plus bath additive®.
      • Physiological lipids (key components of the stratum corneum extracellular lipid lamellae), including ceramides, fatty acids and cholesterol, for example, CeraVe® (cream and lotion).
    • Emollients containing active ingredients are not generally recommended because they increase the risk of skin reactions. However, they may be useful in some people.
  • All emollients are available on the NHS, but some are classified as borderline substances and as such their prescriptions should be endorsed with 'ACBS' (Advisory Committee on Borderline Substances). These include Aveeno® products (bath oil, cream, and lotion), CeraVe® products (cream and lotion), and E45® products (emollient bath oil, emollient wash cream, and lotion).
    • Preparations marked ‘ACBS’ are regarded as drugs when prescribed in accordance with the advice of the ACBS for the clinical conditions listed. See the Drug Tariff for more information.
  • Emollients are also available over-the-counter although availability may be limited.

[BNF, 2022]

Which emollient product should I prescribe?

  • Prescribe an emollient according to the dryness of the skin, and individual preference/tolerance. The key to successful management is finding the correct balance between these factors.
    • Creams and lotions are generally better for red, inflamed areas of skin because it is believed that the evaporation of water-based products cools the skin.
    • Ointments are preferable for dry skin (that is not inflamed) because they are more effective than creams. However, they are usually poorly tolerated compared with cream; this may affect their acceptability and hence compliance.
    • Experience has shown that proprietary products are often preferred to non-proprietary products; it may be a false economy to prescribe solely on the basis of price.
    • Often, several different emollients will be required (for example for different areas of skin, different stages of flare, or for use in different locations).
    • Based on current evidence, it is understood that inter-individual preferences determined after a period of testing will identify the most appropriate emollient [Ridd, 2019].
    • Do not prescribe aqueous cream as a leave-on emollient or as a soap substitute, it contains the ingredient sodium lauryl sulphate, which can irritate the skin and make eczema worse.
  • Where possible, prescribe an emollient with a pump dispenser to minimize the risk of bacterial contamination.
    • For emollients that come in pots, advise that using a clean spoon or spatula (rather than fingers) to remove the emollient helps to minimize contamination.
  • Prescribe emollients to replace soap in people with dry skin requiring treatment.
    • Ointments dissolved in hot water are suitable soap substitutes.
    • Bath additives and shower products are an option for people with extensive areas of dry skin, although the evidence to support their use is limited, and there is no universal consensus on their benefit [DTB, 2007; Eichenfield, 2014b; Santer, 2018]. 
    • If bath emollients are used, it is essential that they do not replace standard emollients [NIHR, 2018]. The person should be advised to continue using standard emollients in addition to any bath emollient product.
  • The effectiveness and acceptability of a particular emollient may vary with time.
    • If the person feels that a particular product has become unsuitable for them (or if they have developed sensitivity to it), prescribe an alternative emollient.
    • It may be necessary to try a range of emollients before the person settles on the best combination.

[NICE, 2007a; SIGN, 2011; Arkwright, 2013; RCN, 2013; Eichenfield, 2015; Primary Care Dermatology Society, 2016; Wollenberg, 2018; Katoh, 2020]

How much emollient should I prescribe?

  • Emollients are typically under-prescribed and under-used. This results in suboptimal treatment of dry skin and eczema, and may increase the occurrence of flares [NICE, 2007a].
  • Once the preferred choice of emollient is known, encourage appropriate usage by prescribing generous amounts (for example 500 g) to be used regularly (often four times daily).
  • Where possible, pump-dispensers should be prescribed when large quantities of cream or lotion are required. This is because they are more convenient than other containers and are less likely to become contaminated by potential pathogens.
  • The amount of emollient used should far exceed other topical treatments (for example corticosteroids) by a factor of at least ten.

[NICE, 2007a; Primary Care Dermatology Society, 2016]

What are the adverse effects of emollients?

  • Skin reactions are the most common adverse effects of emollients. They are caused by sensitivity of the skin to additives in the emollient, such as perfumes, preservatives, and biological components, such as lanolin (although newer hypoallergenic formulations of lanolin are less problematic).
  • If a skin reaction occurs, stop the emollient and use a different one.
  • If the person has had previous skin reactions to emollients, consider testing a small quantity on the skin before widespread application.
  • If sensitivity to emollients is a known problem, prescribe a cream with few additives, or an ointment (ointments do not require preservatives and generally have less excipients), to reduce the chance of a further reaction.
  • The occlusive effect of ointments can cause folliculitis. If this occurs, stop the ointment (consider switching to a cream), and prescribe an antibiotic, if necessary.
  • Aqueous cream is generally not recommended because of the high risk of developing skin reactions.
    • A clinical audit found that the use of aqueous cream results in a significant proportion of people developing sensitization reactions, so it should be avoided [Cork et al, 2003].
    • The Medicines and Healthcare products Regulatory Agency (MHRA) warns that aqueous cream may cause local skin reactions, such as stinging, burning, itching, and redness, when it is used as a leave-on emollient, especially in children with atopic eczema [MHRA, 2013]. The reactions, which are not generally serious, often occur within 20 minutes of application but can occur later, and may be due to sodium lauryl sulfate or other additives [MHRA, 2013].

[NICE, 2007b; National Eczema Society, 2024]

What should I advise on how to use an emollient?

It is essential to provide instructions on the correct use of emollients, with clear demonstrations where appropriate.

  • Advise the person to use emollients liberally and frequently, even when their skin appears improved or is clear.
    • It is recommended that 250–500 g of emollient be applied every week [NICE, 2007a].
    • The frequency of application will vary depending on the person's condition and circumstances, but for very dry skin, application of an emollient every 2–3 hours should be considered normal.
    • To facilitate frequent application, the person should consider keeping separate packs of emollients at work or school.
  • Advise on the appropriate use of emollients.
    • It is particularly important to use emollients during or after washing. The skin should be gently dried and the emollient applied while the skin is still moist [Eichenfield, 2014b; Lyons, 2015; Ng, 2015; BMJ Best Practice, 2022]; experts believe this may help trap moisture in the skin.
    • Emollients should be applied by smoothing them into the skin along the line of hair growth, rather than rubbing them in.
    • It may be more convenient to use better tolerated products (such as creams and lotions) during the day, and ointments (which are usually poorly tolerated) at night.
    • If a topical corticosteroid is prescribed, they should wait several minutes after application of an emollient (about 15–30 mins if possible) before applying the topical corticosteroid [Primary Care Dermatology Society, 2016; SPS, 2020].
      • Due to a lack of quality evidence, the optimal order and timing of application of emollients and topical steroids is not known [SPS, 2020].
    • Emollient products should not be shared with other people as they can become contaminated with bacteria.
      • Pump dispensers minimize the risk of bacterial contamination.
      • For emollients that come in pots, using a clean spoon or spatula (rather than fingers) to remove the emollient helps to minimize contamination.
      • Emollients that have been used during periods where eczema has been infected should be discarded after the infection has cleared. This is because pathogens can contaminate them and survive in product packaging. This applies particularly to creams packaged in tubs and tubes, although the risk is probably less with pump-dispensers [NICE, 2007a; SIGN, 2011].
  • Also advise that:
    • They should avoid the use of soaps, detergents, and bubble bath when washing, as these have an emulsifying effect on the lipids of the skin and can be very damaging to the skin. Instead, a suitable soap substitute should be used, for instance an ointment dissolved in hot water (or lotion in warm water).
    • The MHRA state that both paraffin-containing (any concentration) and paraffin-free emollients present fire hazard risks [MHRA, 2018].
      • Case reports have described both severe and fatal burns with paraffin-containing emollient products, and paraffine-free emollients may also have a fire accelerant effect.
      • It is important that people using emollients and their parents or carers understand the fire risk associated with the build-up of emollient residue on clothing and bedding. People using emollient products should be instructed not to smoke or go near naked flames because clothing or fabric such as bedding or bandages that have been in contact with an emollient or emollient-treated skin can rapidly ignite. Washing clothing or fabric at a high temperature may reduce emollient build-up but not totally remove it.

[NICE, 2007a; SIGN, 2011; RCN, 2013; Primary Care Dermatology Society, 2016]

Topical corticosteroids

Which topical corticosteroids are available?

  • Topical corticosteroids are available in four potencies: mildly potent, moderately potent, potent, and very potent. 
    • These include creams, ointments, lotion, gel, and/or scalp applications, available as non-proprietary and/or proprietary products.
    • Examples include:
      • Mildly potent — hydrocortisone 0.1%, 0.5%, 1.0%, and 2.5%.
      • Moderately potent — betamethasone valerate 0.025% (Betnovate-RD®) and clobetasone butyrate 0.05% (Eumovate®).
      • Potent — betamethasone valerate 0.1% (Betnovate®) and betamethasone dipropionate 0.05% (Diprosone®).
      • Very potent — clobetasol propionate 0.05% (Dermovate®) and diflucortolone valerate 0.3% (Nerisone Forte®).
    • All are available on the NHS with an FP10 form. See the British National Formulary (BNF) for a complete list of all the topical corticosteroids available in the UK. 
  • Note that:
    • Hydrocortisone 1% is available over-the-counter for the treatment of mild-to-moderate eczema not involving the face or genitals.
    • Very potent topical corticosteroids should usually only be prescribed by specialists.
    • Potent corticosteroids should not be used in children under 12 months old, or very potent corticosteroids in children of any age, without specialist dermatological advice.

[NICE, 2007a; BNF, 2022]

What regimen of topical corticosteroid should I prescribe for a flare?

  • For normal skin on the body (not the face, genitals, or axillae):
    • Prescribe a strength of topical corticosteroid to match the severity of the eczema, to be used once a day for 7–14 days:
      • For mild eczema — prescribe a mildly potent topical corticosteroid.
      • For moderate eczema — prescribe a moderately potent corticosteroid.
      • For severe eczema — prescribe a potent topical corticosteroid.
    • The quantities of topical corticosteroid required to treat a flare of eczema for 2 weeks in an adult applying steroids once daily are listed below (about half of this is needed for a child) [BNF, 2022]:
      • Face and neck: 15–30 g.
      • Both hands: 15–30 g.
      • Scalp: 15–30 g.
      • Both arms: 30–60 g.
      • Both legs: 100 g.
      • Trunk: 100 g.
      • Groin and genitalia: 15–30 g. 
    • If the response to once daily application is inadequate, increase to twice daily.
  • For flares on the face, genitals, or axillae, consider prescribing a mild potency topical corticosteroid and increase to a moderate potency corticosteroid only if necessary [SIGN, 2011].
    • For moderate or severe flares on the face, genitals, or axillae, use a moderately potent corticosteroid for a maximum of 5 days [NICE, 2007a]. If this is insufficient, consider referral 
  • Prescribe an appropriate formulation for the person and their condition. Choosing a topical corticosteroid that is acceptable to the person is important as it will encourage compliance with treatment [DTB, 2003].
    • Creams are preferred by most people, especially when used on visible areas, such as the face and hands.
    • Ointments provide the strongest emollient effect and may be more effective. However, they are greasy and so may be more suitable for use at night.
    • Other formulations (such as for scalp applications) are suitable for specific areas of skin.
  • A Technology Appraisal published by the National Institute for Health and Care Excellence (NICE) recommends 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, 2004a]. CKS recommends that cost should be taken into account, but not at the expense of preference.

[NICE, 2007a; SIGN, 2011; Primary Care Dermatology Society, 2016]

Regimen for maintenance

  • For the maintenance treatment of chronic eczema on the body (that is, skin other than the face, genitals, or axillae), consider one of the following treatment options: 
    • Step down treatment — prescribe the lowest potency topical corticosteroid that controls the eczema — typically this will be a potency class down from what is used during a flare (for example prescribe a moderate potency corticosteroid for maintenance in people who have severe flares) [NICE, 2007b].
    • Intermittent treatment — consider one of the following two regimens:
      • Weekend therapy — prescribe the usual topical corticosteroid, to be used on two consecutive days per week [NICE, 2007b].
      • Twice weekly therapy — prescribe the usual topical corticosteroid, to be used twice a week (for example every 3–4 days) [SIGN, 2011].
    • Treatment should be continued indefinitely, although an occasional drug holiday is advisable when step down treatment is being used.
  • For the maintenance treatment of chronic eczema on the face, genitals, or axillae, use a mild topical corticosteroid. If this is insufficient, consider referral.

What do I need to know about prescribing topical corticosteroids?

  • When used correctly, topical corticosteroids rarely cause serious adverse effects.
  • The likelihood of adverse effects is directly related to:
    • Duration of treatment — long-term treatment is likely to result in systemic absorption.
    • Area of the skin being treated — treating large areas of skin increases the risk of systemic absorption.
    • Condition of the skin — absorption is greatest in thin, inflamed skin.
    • Potency of the topical corticosteroid — the greater the potency, the greater the risk of systemic absorption.
    • Occlusion — use of topical corticosteroids under occlusion (bandages/dressings) increases the risk of systemic absorption.
    • Age — children and older people are more susceptible to adverse effects because they have a thinner epidermis. Older people also have reduced dermal collagen (due to age and sun damage).
  • Local adverse effects are more common. They mostly occur on the face, in skin folds, and in areas that are treated over the long term. Local adverse effects include:
    • Transient burning or stinging — this is common, especially in the first 2 days of application on untreated, inflamed skin. It does not usually require a change of treatment, as it improves as the skin responds to treatment.
    • Worsening and spreading of untreated infection.
    • Thinning of the skin — the skin improves after stopping treatment.
    • Permanent striae.
    • Allergic contact dermatitis — due to the corticosteroid or the excipients.
    • Acne vulgaris (or worsening of existing acne) or acne rosacea.
    • Mild depigmentation — usually reversible.
    • Excessive hair growth at the site of application (hypertrichosis).
  • Systemic adverse effects are rare, but may include:
    • Adrenal suppression.
    • Cushing's syndrome.
    • Growth suppression in children.
  • If tachyphylaxis to a topical corticosteroid is suspected in a child, a different topical corticosteroid of the same potency should be considered as an alternative to stepping up treatment to a more potent corticosteroid.
  • For detailed prescribing information on topical corticosteroids, including contraindications and cautions and advice on minimizing adverse effects, see Scenario: Topical treatment in the CKS topic on Corticosteroids - topical (skin), nose, and eyes.

[Arkwright, 2013; Brayfield, 2014; Primary Care Dermatology Society, 2016; BNF, 2022; NICE, 2007a]

What should I advise on how to use a topical corticosteroid?

  • Advise the person on how to apply the topical steroid. They should:
    • Apply the product sparingly to all the affected areas. Most products will be supplied with an information leaflet which will specify the number of finger-tip units (FTUs) needed to treat specific body areas.
      • One FTU is equivalent to about 500 mg and is sufficient to treat a skin area about twice that of the flat of the hand with the fingers together. The approximate quantity that should be applied for each area of the body is listed in Table 2.
    • If a topical corticosteroid is prescribed, they should wait several minutes after application of an emollient (about 15–30 mins if possible) before applying the topical corticosteroid [Primary Care Dermatology Society, 2016; SPS, 2020] (only after the emollient has been fully absorbed).
      • Due to a lack of quality evidence, the optimal order and timing of application of emollients and topical steroids is not known [SPS, 2020].
      • NICE states that individual preference should determine which product is applied first [NICE, 2007a].
      • Apply their topical corticosteroid at a time of the day most convenient to them, for example just after the person has washed and applied emollients and/or at night before sleep (this is particularly suitable if they are using ointments).
  • For flares of eczema, advise the person to:
    • Apply the topical corticosteroid no more than twice a day. For many people, once daily application will be sufficient, but this can be increased if there is an inadequate response.
    • Continue treatment for 48 hours after the eczema has cleared (if it has not improved after 2 weeks, the person should return for further advice).
  • For maintenance of chronic eczema, advise the person:
    • To apply the topical corticosteroid once daily (on treatment days).
    • That the treatment should be continued indefinitely, although an occasional drug holiday is advisable when step down treatment is being used.

Table 2. Quantity of topical corticosteroid to apply for one application.

Body areaNumber of finger-tip units* (FTUs) for adults and children
Face and neckAdult: 2.5 
Children: 6–10 years: 2; 3–5 years: 1.5; 1–2 years: 1.5; 3–12 months: 1
Arm and handAdult: 4 
Children: 6–10 years: 2.5; 3–5 years: 2; 1–2 years: 1.5; 3–12 months: 1
Leg and footAdult: 8 
Children: 6–10 years: 4.5;3–5 years: 3; 1–2 years: 2; 3–12 months: 1.5
Trunk (front)Adult: 7 
Children: 6–10 years: 3.5; 3–5 years: 3; 1–2 years: 2; 3–12 months: 1
Trunk (back) including buttocksAdult: 7 
Children: 6–10 years: 5; 3–5 years: 3.5; 1–2 years: 3; 3–12 months: 1.5
* One adult fingertip unit (FTU) is the amount of ointment or cream expressed from a tube with a standard 5mm diameter nozzle, applied from the distal crease to the tip of the index finger.
Data from: [SGUH, 2017]

Topical calcineurin inhibitors

What do I need to know about prescribing topical calcineurin inhibitors?

  • Topical calcineurin inhibitors are non-steroidal immunomodulatory agents licensed for the treatment of atopic eczema. Two topical calcineurin inhibitors are available [BNF, 2022]:
    • Tacrolimus 0.03% and 0.1% ointments; licensed for for children 2 years of age and older (0.03%), and adolescents or adults (0.1%, 16 years of age and older).
    • Pimecrolimus 1% cream; licensed for children 3 months of age and older, adolescents and adults.
  • Use of topical calcineurin inhibitors may be considered in the second-line treatment of moderate to severe ectopic eczema [NICE, 2007a].
    • Long-term topical corticosteroid treatment can result in skin atrophy, whereby the skin becomes thin and loses some of its function. This is more likely to occur in areas where the skin is already thin, such as the face (particularly the eyelids/periorbital region) and flexures [NICE, 2007a; Wollenberg, 2018; Primary Care Dermatology Society, 2016; SIGN, 2011].
      • Topical calcineurin inhibitors have a lower risk of skin thinning [Axon, 2021].
  • Short term use of topical calcineurin inhibitors may be beneficial where moderate to severe eczema has not been controlled by topical corticosteroids, or where there is a risk of serious adverse effects from prolonged corticosteroid use, particularly skin atrophy [SIGN, 2011].
    • NICE state that atopic eczema uncontrolled 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.
    • Stepping up treatment to topical calcineurin inhibitors may be beneficial for children with facial atopic eczema requiring long-term or frequent use of mild topical corticosteroids [NICE, 2007a; Primary Care Dermatology Society, 2016; Wollenberg, 2018].
  • Use of topical calcineurin inhibitors should not be considered for the treatment of mild atopic eczema, nor as a first line treatment option for eczema of any severity [NICE, 2007a].
  • Prolonged systemic use of calcineurin inhibitors in transplant patients has been associated with an increased risk of developing lymphomas and skin malignancies [ABPI, 2021a].
    • Short-term use of topical calcineurin inhibitors is unlikely to present a risk of malignancy [ABPI, 2021a].
      • Topical tacrolimus has not been observed to produce systemic concentrations similar to those observed with sytemic use.
      • A large propsective cohort study including approximately 45,000 years of follow-up data did not identify an increased risk of malignancy among those exposed to topical tacrolimus [Paller, 2020].
  • NICE recommendations state [NICE, 2004b].
    • Topical tacrolimus may be considered, within its licensed indications, as a second-line treatment option for moderate to severe atopic eczema in adults and children aged 2 years and older.
    • Topical pimecrolimus may be considered, within its licensed indications, as a second-line treatment option for moderate atopic eczema on the face and neck in children aged 2 to 16 years.
  • Treatment with tacrolimus or pimecrolimus should only be initiated by physicians (including general practitioners) with a special interest and experience in dermatology [NICE, 2007a]. Careful consideration and discussion of the potential risks and benefits of all appropriate second-line treatment options is required. See Usage instructions for more information.

What should I advise on how to use topical calcineurin inhibitors?

  • Advise on how to apply the product:
    • Topical calcineurin inhibitors should only be applied to areas of active atopic eczema, which may include areas of broken skin.
    • Both tacrolimus and pimecrolimus are applied as a thin layer to the affected areas, up to twice daily, and may be used on any part of the body, except on mucous membranes.
    • As a precaution against impairing the normal immunological response to infection, topical calcineurin inhibitors should not be applied to skin which appears actively infected.
    • Frequency of use is determined by the clinical scenario. For more information see recommendations provided in the BNF for Children (tacrolimus 0.03% ointment and 1% pimecrolimus cream), or the BNF (0.03% or 0.1% tacrolimus ointment and 1% pimecrolimus cream).
  • Also advise that:
    • Topical calcineurin inhibitors should not be used under bandages or dressings. Specialist dermatological advice should be sought if required.
    • Exposure of the skin to sunlight, UV light from a solarium, therapy with UVB or UVA in combination with psoralens should be avoided during treatment.
      • Appropriate sun protection methods should be advised including minimising time spent in direct sunlight, use of sunscreen products, and keeping the skin covered with appropriate clothing.
    • Common adverse effects include mild and short acting skin irritation reactions at the site of application.
      • Topical tacrolimus has also been linked with erythema, folliculitis, herpes simplex infection, acne, increased sensitivity to hot and cold, and alcohol intolerance.
      • Topical pimecrolimus has been linked with erythema, skin infections (including folliculitis, herpes simplex and zoster and molluscum contagiosum), and local reactions such as pain, paraesthesia, peeling, dryness, oedema and worsening of eczema.

[NICE, 2007a; NICE, 2004b; SIGN, 2011; BNF, 2022; BNFC, 2022]

Oral antihistamines

What do I need to know about prescribing oral antihistamines?

  • Antihistamines are not recommended for routine use in the management of atopic eczema. See the section on Management for more information.
  • However:
    • If there is severe itch or urticaria, consider prescribing a one-month trial of a non-sedating antihistamine, such as cetirizine, loratadine, or fexofenadine (an active metabolite of terfenadine), provided there are no contraindications. 
      • For detailed information on prescribing these antihistamine, including contraindication and cautions, recommended doses, choices in pregnancy and breastfeeding, choices for children, and adverse effects, see the Prescribing information section in the CKS topic on Urticaria.
    • If itching is severe and affecting sleep, consider prescribing a short course (maximum or two weeks) of a sedating antihistamine, such as chlorphenamine.
      • For detailed information on prescribing chlorphenamine, including contraindication and cautions, recommended doses, adverse effects, and drug interactions, see the Prescribing information section in the CKS topic on Urticaria.
  • Antihistamines are not licensed for use in atopic eczema. However, they are licensed for allergic conditions, including urticaria (a condition where itch is the predominant symptom).

[NICE, 2007a]

What should I advise on how to use an oral antihistamine?

  • Advise that:
    • Some people may experience sedation with antihistamines, which may affect their ability to drive.
    • The sedative effects of antihistamines are enhanced when they are combined with alcohol.
      • Sedating antihistamines, including chlorphenamine, cause sedation in 10–50% of people, which can persist into the next day.
      • Non-sedating antihistamines are less likely to cause drowsiness and sedation (because these drugs penetrate the blood–brain barrier to a lesser extent than sedating antihistamines); however, the person should still be made aware of this potential adverse effect.
    • Rare reported adverse effects include nightmares, acute generalized exanthematous pustulosis and arthralgia. 

[DTB, 2002; ABPI, 2019; BNF, 2022]

Oral corticosteroids

What do I need to know about prescribing oral corticosteroids?

Oral corticosteroids should be reserved for use in the treatment of severe flares, often while waiting for referral to secondary care where the condition can be fully assessed and other treatment options can be tried [Drucker, 2018]. See Scenario: Severe eczema for more information.

  • Be aware that:
    • There is no evidence from controlled trials to support the effectiveness of oral corticosteroids, but clinical experience suggests that there is a large and rapid treatment effect.
    • Prolonged or frequent treatment should be avoided as there is a cumulative risk of serious adverse effects including growth restriction in children, diabetes mellitus, high blood pressure, and osteoporosis [Schmitt et al, 2007; Werfel, 2016; Drucker, 2018; Wollenberg, 2018]. However, these are unlikely to be a problem with a single course of prednisolone.
    • It is not necessary to taper the dose when stopping a one-week course of prednisolone.
  • For detailed prescribing information on oral corticosteroids, including contraindications and cautions, adverse effects, and drug interactions, see the CKS topic on Corticosteroids - oral.

What should I advise on how to use an oral corticosteroid?

  • Advise the person that:
    • Oral corticosteroids will have an immediate impact on the eczema and make them feel better, but they are for exceptional use and cannot be prescribed very often.
    • The use of topical corticosteroids is not necessary while oral prednisolone is being used (although emollients should still be used). However, they should use potent topical corticosteroids on the affected areas when the oral course has finished, as there is a risk of rebound eczema occurring after discontinuation of prednisolone.

[Charman and Williams, 2003]

Oral antibiotics

What do I need to know about prescribing flucloxacillin?

  • Flucloxacillin is licensed for the treatment of infected skin conditions, including eczema.
  • Dosing regime
    • The usual doses (which should be taken at least 30 minutes before food) are [BNF, 2022; BNFC, 2022; NICE, 2021]:
      • Adults — 500 mg four times a day for 5–7 days. 
      • Children 10–17 years of age — 250 mg to 500 mg four times a day for 5–7 days.
      • Children 2–9 years of age — 125 mg to 250 mg four times a day for 5–7 days.
      • Children 1 month to 23 months of age — 62.5 mg to 125 mg four times a day for 5–7 days.
  • Contraindications and cautions 
    • Do not prescribe flucloxacillin to people with:
      • A true penicillin hypersensitivity. Gastrointestinal adverse effects alone (such as nausea, vomiting, or diarrhoea) do not constitute an allergy to penicillin.
      • History of penicillin-associated hepatic dysfunction.
    • Prescribe flucloxacillin with caution to people with:
      • Hypersensitivity to cephalosporins.
      • Hepatic impairment.
      • Renal impairment — consider dose reduction, or a reduction in dosing interval, of flucloxacillin in severe renal failure, due to the risk of neurotoxicity.
  • Adverse effects
    • The most common adverse effects of flucloxacillin are nausea, vomiting, skin rash, and diarrhoea.
      • Consider pseudomembranous colitis, an acute, exudative colitis caused by Clostridium difficile (a Gram-positive toxin-releasing bacillus), if a person develops severe diarrhoea during or after treatment with flucloxacillin. For more information, see the CKS topic on Diarrhoea - antibiotic associated.
    • Anaphylaxis (delayed or immediate) is a serious but rare adverse effect of flucloxacillin. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
    • Hepatitis and cholestatic jaundice may occur very rarely after treatment with flucloxacillin. These reactions are related neither to the dose nor to the route of administration of flucloxacillin, and the onset may be delayed for several weeks (up to 2 months) after treatment has stopped. Risk factors include treatment for more than 2 weeks and increasing age [ABPI, 2021b].
  • Possible drug interactions with flucloxacillin include:
    • Methotrexate — methotrexate clearance may be reduced, causing an increased risk of toxicity, however, serious interactions are uncommon. 
      • Standard routine monitoring will identify any decreases in elimination in people on high-dose regimens. For people on low-dose regimens, consult local or national guidelines/protocols for monitoring and management.
    • Coumarin and indanedione anticoagulants (warfarin, phenidione) — consider increased monitoring of international normalized ratio (INR) and adjust the dose accordingly.
    • Posaconazole, voriconazole — concentrations of antifungal is greatly decreased. If concurrent use is unavoidable, monitor for decreased efficacy and consider increasing the dose of the azole (although this may not resolve the issue). 
    • Probenecid — concomitant administration may result in increased levels of flucloxacillin.
    • Live cholera vaccine — efficacy of vaccine may be reduced. Avoid flucloxacillin from 14 days before to 10 days after receiving live cholera vaccine.
    • Live typhoid vaccine — immune response to vaccine may be reduced. Avoid flucloxacillin from 3 days before to 3 days after receiving live typhoid vaccine.

     

  • Flucloxacillin is not known to be harmful during pregnancy and breastfeeding [BNF, 2022].

[Preston, 2016; CoSRH, 2017; ABPI, 2021b; Preston, 2023]

What do I need to know about prescribing erythromycin?

  • Erythromycin is licensed for skin and soft tissue infections.
  • Dosing regime
  • Contraindications and cautions
    • Do not prescribe erythromycin to people with:
      • Porphyria.
      • A history of QT interval prolongation or ventricular cardiac arrhythmia.
      • Conditions that predispose to QT interval prolongation such as electrolyte disturbances and people taking drugs that prolong the QT interval.
    • Prescribe erythromycin with caution to people with:
      • Impaired hepatic function (or people concomitantly receiving potentially hepatotoxic drugs) — erythromycin is principally excreted by the liver. 
      • Renal impairment — give a maximum of 1.5 g daily in severe renal impairment, due to the risk of ototoxicity. 
      • Myasthenia gravis — macrolide antibiotics may aggravate weakness symptoms in people with myasthenia gravis.
  • Adverse effects
    • Gastrointestinal adverse effects, such as nausea, vomiting, and diarrhoea, are common in people taking erythromycin.
    • Consider pseudomembranous colitis, an acute, exudative colitis caused by Clostridium difficile (a Gram-positive toxin-releasing bacillus), if a person develops severe diarrhoea during or after treatment with erythromycin. For more information, see the CKS topic on Diarrhoea - antibiotic associated.
    • Hepatic dysfunction, including increased liver enzymes and cholestatic hepatitis (with or without jaundice), has been rarely reported with erythromycin.
  • Possible drug interactions with erythromycin include:
    • Amisulpride — concurrent use with erythromycin is contraindicated.
      • There is an increased risk of ventricular arrhythmias when erythromycin given with amisulpride.
    • Cimetidine — monitor concurrent use closely as a dose reduction of erythromycin may be necessary.
      • Cimetidine may inhibit the metabolism of erythromycin, leading to an increased plasma concentration.
    • Calcium channel blockers — concurrent use of erythromycin and calcium channel blockers metabolized by cytochrome CYP3A4 (such as verapamil) should be done cautiously.
      • There is an increased risk of hypotension during concurrent treatment with erythromycin.
    • Colchicine — suspend or reduce dose of colchicine (avoid concomitant use in hepatic or renal impairment).
      • Colchicine toxicity has been reported following concomitant use with erythromycin.
    • Carbamazepine — monitor carbamazepine levels within 3–5 days of starting erythromycin, and adjust the dose accordingly. 
      • Erythromycin can increase carbamazepine levels, causing carbamazepine toxicity (which may present as nausea and vomiting, ataxia, and drowsiness).
    • Corticosteroids — levels of corticosteroids may be increased. Monitor for corticosteroid adverse effects (such as moon face, weight gain, hyperglycaemia), and adjust the corticosteroid dose or stop the macrolide as appropriate. 
    • Domperidone — concurrent use with erythromycin is contraindicated.
      • Erythromycin increases plasma concentration of domperidone (increased risk of ventricular arrhythmias).
    • Drugs that prolong the QT interval — if possible, avoid giving erythromycin to a person who is already taking a drug that can potentially prolong the QT interval.
      • Macrolides can also prolong the QT interval.
    • Ergotamine and dihydroergotamine — concurrent use with erythromycin is contraindicated by the manufacturer of erythromycin.
      • Increased risk of ergotism when erythromycin is given with ergot alkaloids.
    • Lomitapide — concurrent use with erythromycin increases transaminase levels and is contraindicated.
    • Mizolastine — concurrent use with erythromycin is contraindicated.
      • Macrolides possibly inhibit metabolism of mizolastine.
    • Pimozide — concurrent use with erythromycin is contraindicated.
      • Possible increased risk of ventricular arrhythmias when erythromycin given with pimozide.
    • Quetiapine — avoid concurrent use.
      •  Erythromycin increases plasma concentration of quetiapine.
    • Reboxetine — avoidance of macrolides advised by manufacturer of reboxetine.
    • Rifabutin — dose reduction of rifabutin may be needed.
      • Erythromycin possibly increases plasma concentration of rifabutin (increased risk of toxicity). 
    • Rivaroxaban — erythromycin may increase levels of rivaroxaban, increasing the risk of bleeding. 
    • Statins — there is an increased risk of myopathy.
      • For simvastatin — do not prescribe erythromycin to a person taking simvastatin. Consider temporarily stopping simvastatin during short-term treatment with erythromycin. 
      • For atorvastatin — avoid concurrent use with erythromycin if possible. Consider temporarily stopping atorvastatin during short-term treatment with erythromycin. If concurrent use cannot be avoided, prescribe the lowest starting dose of atorvastatin (10 mg), and advise the person to report any muscle pain, tenderness, or weakness.
      • For pravastatin — prescribe erythromycin with caution, and advise the person to seek medical advice if they experience symptoms of myopathy (for example muscle pain, tenderness, or weakness).
      • Other statins — clinically significant interaction with erythromycin is not expected for rosuvastatin and fluvastatin. Nevertheless, advise the person to report any muscle pain, tenderness, or weakness. 
    • Theophylline — consider using clarithromycin (in preference to erythromycin) as clarithromycin normally causes only modest (clinically unimportant) increases in theophylline levels.
      • Concurrent use of erythromycin with high doses of theophylline may be associated with an increase in serum theophylline levels and potential theophylline toxicity (which may present as palpitations, nausea, tremor, and headache). If this is suspected, reduce the dose of theophylline. 
      • Concurrent treatment may also result in a significant decrease in erythromycin serum concentrations, leading to sub-therapeutic concentrations of erythromycin.
    • Tolterodine — concurrent administration with erythromycin is contraindicated by manufacturer of tolterodine.
      • Concurrent use is likely to result in an enhanced risk of cardio toxicity with tolterodine.
    • Venlafaxine — avoid concurrent use.
      • There is a risk of ventricular arrhythmias following concurrent use with erythromycin.
    • Warfarin — monitor the international normalized ratio (INR) when both drugs are used concurrently (particularly in elderly people), and adjust the warfarin dose accordingly.
      • Erythromycin may enhance the effect of warfarin. This is an established but unpredictable interaction.
    • Zopiclone — monitor concurrent use.
      • Erythromycin has been reported to decrease the clearance of zopiclone; this may lead to an increase in the effects of zopiclone. 
    • Oral hormonal contraception — additional contraceptive precautions are not required during or after courses of erythromycin. 
  • The BNF states that erythromycin use in pregnancy should only be considered if the potential benefits outweigh the risks [BNF, 2022].
    • The UK Teratology Information Service state that the majority of the available data do not provide evidence that macrolide use in pregnancy increases the risk of adverse pregnancy outcome, however, a limited number of studies have described small increased risks of malformation and miscarriage (see their summary for more information).
    • Macrolide use in pregnancy should therefore be reserved for compelling indications where there are no suitable alternatives with adequate pregnancy safety data.
    • Erthromycin is considered the preferred macrolide for use during pregnancy as an increased amount of safety data are available (for more details see the MHRA Public Assessment Report on the safety of macrolide antibiotics in pregnancy).

[Preston, 2016; CoSRH, 2017; MHRA, 2020; NICE, 2021; ABPI, 2021c]

What do I need to know about prescribing clarithromycin

  • Clarithromycin is indicated for the treatment of skin and soft tissue infections of mild to moderate severity.
  • The recommended doses are [BNF, 2022; BNFC, 2022; NICE, 2021]:
    • Adults and children older than 12 years of age — 250 mg to 500 mg (in severe infection) twice daily for 5–7 days.
    • Children 1 month to 11 years of age:
      • Body weight 30–40 kg — 250 mg twice daily for 5–7 days. 
      • Body weight 20–29 kg — 187.5 mg twice daily for 5–7 days.
      • Body weight 12–19 kg — 125 mg twice daily for 5–7 days. 
      • Body weight 8–11 kg — 62.5 mg twice daily for 5–7 days. 
      • Body weight less than 8 kg — 7.5 mg per kg twice daily for 5–7 days. 
  • Contraindications and cautions
    • Do not prescribe clarithromycin to people with:
      • A history of QT prolongation or ventricular cardiac arrhythmia, including Torsades de pointes arrhythmias.
      • Hypokalaemia.
      • Severe hepatic impairment in combination with renal impairment.
    • Prescribe clarithromycin with caution to people with:
      • Impaired hepatic function (or concomitantly receiving potentially hepatotoxic drugs) — clarithromycin is principally excreted by the liver. Hepatic dysfunction, including increased liver enzymes and cholestatic hepatitis (with or without jaundice), has been rarely reported with its use.
      • Conditions which predispose to QT interval prolongation, such as electrolyte disturbances, and people taking drugs that prolong the QT interval, for example amiodarone, sotalol, terfenadine,and amisulpride — macrolides can also prolong the QT interval, increasing the risk of Torsades de pointes arrhythmias.
      • Chronic kidney disease (CKD) stages 4 and 5. 
      • Coronary artery disease, severe cardiac insufficiency, or bradycardia (less than 50 beats per minute) — increased risk of QT interval prolongation.
      • Myasthenia gravis.
  • Adverse effects
    • The most common adverse effects of clarithromycin are nausea, vomiting, abdominal discomfort, and diarrhoea.
      • Consider pseudomembranous colitis, an acute, exudative colitis caused by Clostridium difficile (a Gram-positive toxin-releasing bacillus), if a person develops severe diarrhoea during or after treatment with clarithromycin. For more information, see the CKS topic on Diarrhoea - antibiotic associated.
    • Hepatotoxicity (including cholestatic jaundice) and rash have less frequently been reported.
    • Anaphylaxis is rarely associated with clarithromycin. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
    • Reversible hearing loss (sometimes with tinnitus) can occur after large doses of clarithromycin.
    • Other adverse effects reported rarely or very rarely include pancreatitis, QT interval prolongation, arrhythmias, Stevens-Johnson syndrome, and toxic epidermal necrolysis.
  • Possible drug interactions with clarithromycin include:
    • Carbamazepine — reduce the dose of carbamazepine by 30–50% during treatment with clarithromycin, or consider prescribing azithromycin, if appropriate.
      • Advise the person to report symptoms of carbamazepine toxicity (such as dizziness, diplopia, ataxia, or confusion).
    • Calcium channel blockers — concurrent use of clarithromycin and calcium channel blockers metabolized by cytochrome CYP3A4 (such as verapamil, amlodipine, and diltiazem) should be done cautiously.
      • There is an increased risk of hypotension during concurrent treatment with clarithromycin.
    • Colchicine — suspend or reduce dose of colchicine (avoid concomitant use in hepatic or renal impairment).
      • Clarithromycin possibly increases risk of colchicine toxicity. 
    • Domperidone — avoid concurrent use.
      • There is a possible increased risk of ventricular arrhythmias when clarithromycin given with domperidone.
    • Drugs that prolong the QT interval (such as anti-arrhythmics, antipsychotics, and tricyclic antidepressants) — seek advice from a medical microbiologist regarding a suitable alternative antibiotic.
      • All macrolides can prolong the QT interval, and concomitant use of drugs that prolong the QT interval is not recommended.
    • Drugs that cause hypokalaemia (such as diuretics, corticosteroids, short-acting beta2-agonists) — seek advice from a medical microbiologist regarding a suitable alternative antibiotic.
      • Hypokalaemia is a risk factor for QT prolongation.
    • Ergotamine and dihydroergotamine — concurrent use with clarithromycin is contraindicated by the manufacturer of clarithromycin.
      • Increased risk of ergotism when clarithromycin is given with ergot alkaloids.
    • Edoxaban — manufacturer advises caution with concurrent treatment with edoxaban, particularly in those with a high risk of bleeding.
    • Itraconazole — clarithromycin increases the plasma concentration of itraconazole, owing to CYP3A4 inhibition by clarithromycin which can cause elevated levels of ivabradine.
    • Ivabradine — concomitant treatment is contra-indicated, owing to CYP3A4 inhibition by clarithromycin which can cause elevated levels of ivabradine.
    • Midazolam — concurrent use should be done with caution.
      • Clarithromycin inhibits metabolism of midazolam (increased plasma concentration with increased sedation).
    • Mizolastine — avoid concurrent use. 
      • Macrolides possibly inhibit metabolism of mizolastine.
    • Pimozide — concurrent use with clarithromycin is contraindicated.
      • Possible increased risk of ventricular arrhythmias when clarithromycin given with pimozide.
    • Quetiapine — avoid concurrent use.
      •  Clarithromycin increases plasma concentration of quetiapine.
    • Reboxetine — avoidance of macrolides advised by manufacturer of reboxetine.
    • Rifabutin — dose reduction of rifabutin may be needed.
      • Clarithromycin possibly increases plasma concentration of rifabutin (increased risk of toxicity). 
    • Sildenafil — consider reducing initial dose of sildenafil.
      • Clarithromycin increases the plasma concentration of sildenafil.
    • Statins — there is an increased risk of myopathy (due to cytochrome P450 enzyme CYP3A4 inhibition) if clarithromycin is taken with atorvastatin or simvastatin.
      • For simvastatin — do not prescribe clarithromycin to a person taking simvastatin, as simvastatin is extensively metabolized by CYP3A4. If clarithromycin treatment cannot be avoided, stop treatment with simvastatin during the course of the treatment.
      • For atorvastatin — avoid concurrent use with clarithromycin as atorvastatin is moderately metabolized by CYP3A4. If concurrent use cannot be avoided, prescribe the lowest starting dose of atorvastatin (that is 10 mg), and advise the person to report any muscle pain, tenderness, or weakness.
      • Other statins — clinically significant drug interactions resulting from cytochrome P450-mediated metabolism are not expected for rosuvastatin and pravastatin as they are not metabolized to a clinically significant extent by the cytochrome P450 system. Fluvastatin is not dependent on CYP3A metabolism, so an interaction with clarithromycin is unlikely. Nevertheless, advise the person to report any muscle pain, tenderness, or weakness.
    • Warfarin — occasionally and unpredictably, the effects of warfarin may be markedly increased by macrolides.
      • Monitor the international normalized ratio (INR), and adjust the warfarin dose accordingly.
    • Antidiabetic drugs and insulin — the concurrent use of clarithromycin and antidiabetic drugs (such as sulphonylureas and/or insulin) can result in significant hypoglycaemia.
      • Monitor blood glucose levels more regularly, and adjust the antidiabetic drug (and/or insulin) dose accordingly.
    • Contraceptives — additional contraceptive precautions are not required during or after a course of clarithromycin.
  • Erythromycin is the macrolide of choice in pregnant and breastfeeding women. Clarithromycin should only be considered if the woman cannot tolerate erythromycin and there is no suitable alternative (for more details see the MHRA Public Assessment Report on the safety of macrolide antibiotics in pregnancy).

 [Preston, 2016; CoSRH, 2017; EMC, 2024]

What should I advise on how to use oral antibiotics?

  • Advise the person:
    • To complete the treatment course as directed.
    • To continue treatment with topical corticosteroids and emollients while taking antibiotics.
    • That gastrointestinal adverse effects (such as nausea, vomiting, or diarrhoea) can sometimes occur with all antibiotics. However, these are particularly common with erythromycin.
      • If the person experiences severe symptoms, they should return for a trial of an alternative antibiotic (for example clarithromycin).
    • That additional contraceptive precautions are not required during or after courses of broad spectrum antibiotics.
  • Also advise people taking flucloxacillin that some people are allergic to penicillin antibiotics (including flucloxacillin). They should seek urgent medical advice if they develop a severe rash; there is swelling of the face, hands or feet; or they feel short of breath.

 [NICE, 2007a; CoSRH, 2017; NICE, 2021; BNF, 2022]

Topical antibiotics and antiseptics

What do I need to know about prescribing topical antiseptics and antibiotics?

  • Antiseptics are used to lower bacterial load. They include solutions of chlorhexidine salts and triclosan, potassium permanganate, and antiseptics incorporated into emollients [Wollenberg, 2018].
  • A range of topical antiseptics and antibiotics are available, either alone or combined with emollients or topical corticosteroids [Wollenberg, 2018].
  • If a topical antibiotic alone is prescribed, the recommended option is fusidic acid 2% [NICE, 2021]. Advise that continued treatment with a topical corticosteroid should also form part of the treatment plan.
    • Avoid using combined corticosteroid/antibiotic preparations (such as Fucibet® cream) as this will increase the risk of antibiotic resistance [Primary Care Dermatology Society, 2016].
    • If prescribing combined products, generally the same issues and precautions apply as with topical corticosteroids alone. However, sensitization is more likely to occur because of the inclusion of more additives.

What should I advise on how to use a topical antibiotic or antiseptic?

  • Advise the person:
    • Apply fusidic acid 2% three times a day for 5–7 days on the affected areas. 
    • Not to use fusidic acid for more than 7 days (due to the increased risk of sensitization and bacterial resistance).
    • That if their skin worsens during treatment, they should stop using the product and seek medical advice.
      • This may be a sign of sensitization or an indication that the product is not effectively treating the infection.
      • Oral antibiotics may be required.

[NICE, 2021]

Supporting evidence

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guidelines Atopic eczema in under 12s: diagnosis and management [NICE, 2007a] and Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing [NICE, 2021].

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of atopic eczema.

Search dates

March 2017 - February 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Eczema/, eczema.tw., atopic eczema.tw., exp Dermatitis, Atopic/, atopic dermatitis.tw.
  • corticosteroid$.tw
  • Atopic eczema or infantile eczema or childhood eczema.ti,ab.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • ABPI (2019) SmPC: Zirtek Allergy 10 mg film-coated Tablets. ABPI. http://www.medicines.org.uk [Free Full-text]
  • ABPI (2021a) SmPC: Protopic 0.1% ointment. ABPI. [Free Full-text]
  • ABPI (2021b) Flucloxacillin 250mg Capsules. ABPI. http://www.medicines.org.uk [Free Full-text]
  • ABPI (2021c) SmPC: Erythromycin Tablets BP 250 mg. ABPI. http://www.medicines.org.uk [Free Full-text]
  • Abuabara, K., Magyari, A., McCulloch, C.E., et al. (2019) Prevalence of Atopic Eczema Among Patients Seen in Primary Care: Data From The Health Improvement Network. Ann Intern Med 170(5), 354-356. [Abstract] [Free Full-text]
  • Akdis, C.A., Akdis, M., Bieber, T., et al. (2006) Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report. Allergy 61(8), 969-987. [Abstract]
  • Arkwright, P.D. and Motala, C.,  Subramanian, H. et al. (2013) Management of difficult-to-treat atopic dermatitis. The Journal of Allergy and Clinical Immunology 1(2), 142-151. [Abstract] [Free Full-text]
  • Axon, E., Chalmers, J.R., Santer, M., et al. (2021) Safety of topical corticosteroids in atopic eczema: an umbrella review. BMJ Open 11(7), e046476. [Abstract] [Free Full-text]
  • BAD (2017) Atopic eczema. Patient Information Leaflets. British Association of Dermatologists. http://www.bad.org.uk [Free Full-text]
  • Bamford, J.T., Ray, S. and Musekiwa, A. et al. (2013) Oral evening primrose oil and borage oil for eczema. The Cochrane Library. John Wiley & Sons, Ltd. http://www.thecochranelibrary.com [Free Full-text]
  • Baron,S.E., Cohen,S.N., Archer,C.B. and British Association of Dermatologists and Royal College of General Practitioners (2012) Guidance on the diagnosis and clinical management of atopic eczema. Clinical and Experimental Dermatology. 37 Suppl 1, 7-12. [Abstract]
  • Bath-Hextall, F. and Williams, H. (2007) Eczema (atopic). Clinical Evidence. BMJ Publishing Ltd. http://www.clinicalevidence.com
  • Bath-Hextall, F., Delamere, F.M. and Williams, H.C. (2008a) Dietary exclusions for established atopic eczema (Cochrane Review). The Cochrane Library. John Wiley & Sons, Ltd. http://www.thecochranelibrary.com [Free Full-text]
  • Bath-Hextall, F., Delamere, F.M. and Williams, H.C. (2008b) Dietary exclusions for established atopic eczema (Cochrane Review). John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Beltrani, V.S. and Boguneiwicz, M. (2003) Atopic dermatitis. Dermatology Online Journal 9(2), 1.
  • Herbert, A.A. and Galindo E.G. (2022) Eczema. BMJ. https://bestpractice.bmj.com/topics/en-gb/87
  • BMJ (2016) Atopic dermatitis. BMJ Best practice.. www.bestpractice.bmj.com
  • BNF (2022) British National Formulary. National Institute for Health and Care Excellence (NICE). https://bnf.nice.org.uk
  • Royal Pharmaceutical Society and BMJ Group (2022) British National Formulary for Children. National Institute for Health and Care Excellence (NICE). https://bnfc.nice.org.uk
  • Brayfield, A. (ed.) (2014) Martindale: the complete drug reference. Pharmaceutical Press.
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