New eczema guidelines promote use of emollients, then topical corticosteroids

August 11, 2008

The National Institute for Health and Clinical Excellence published clinical guidelines in December 2007 on diagnosis and management of eczema in children.

In December 2007 the National Institute for Health and Clinical Excellence (NICE) published its clinical guidelines on the diagnosis, evaluation, and management of atopic eczema in children 12 years of age, replacing the 2006 British Association of Dermatology and Primary Care Dermatology Society guidelines.

The NICE guidelines promote a stepwise approach to management, with regular emollients and intermittent topical corticosteroids forming the basis of treatment and topical calcineurin inhibitors as second-line treatments. Some recommendations have strong evidence to support them, indicated by a Level 1+ or Level 1++, depending on the meta-analysis or randomized clinical trials used to support the recommendations. The guidelines are evidence-based and also use a modified Delphi technique to formulate recommendations when substantial research evidence is lacking.

Per the guidelines, topical corticosteroids should only be applied to areas of active eczema, which may include areas of broken skin. There is a strong level of evidence to support tailoring the potency of topical corticosteroids based on the severity of a child's eczema. Mild-potency corticosteroids are recommended for the face and neck, except for the short-term (three- to five-day) use of moderate-potency steroids for severe flares. Moderate or potent preparations are recommended for short periods (seven to 14 days) for flares in vulnerable sites such as the axillae and groin.

Topical steroids are also recommended to prevent flares in children with frequent flares after the eczema has been controlled. According to the guidelines, patients should be offered information on how to recognize flares and should be given clear instructions on how to manage them. This is a topic in which Siu believes pharmacists can play an important role.

For patients whose eczema is not controlled by topical corticosteroids or when there is a serious risk of adverse events from topical corticosteroids, there is a strong level of evidence to support the use of topical tacrolimus or pimecrolimus. The guidelines do not recommend the use of oral antihistamines for routine use. In children with mild or moderate eczema in which there is severe itching or urticaria, a one-month trial of a non-sedating antihistamine could be utilized. In children with infections, the guidelines recommend that flucloxacillin be used as a first-line treatment to treat active Staphylococcus aureus and streptococcus for one to two weeks according to clinical response. If children are allergic or have resistance to flucloxacillin, the guidelines recommend the use of erythromycin.

There are numerous over-the-counter products used to treat eczema in children. The complete NICE guidelines are published by the National Collaborating Centre for Women's and Children's Health, and are available at http://www.nice.org.uk/CG057fullguidelineand the National Library for Health ( http://www.library.nhs.uk/rss/).

THE AUTHOR is a writer based in New Jersey.