This document incorporates and summarises guidelines recently published by the American Academy of Dermatology [1] and the British Association of Dermatologists [2]. It is relevant to the treatment of eczema in New Zealand.
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Eczema is a chronic inflammatory skin disease that affects about 20% of children [3,4] and 3% of adults. It is characterized by pruritus, scratching, and eczematous lesions (dry, scaling and crusted areas of skin), and when chronic may be associated with lichenification (thickening) and pigmentary changes. It follows a relapsing course with flares at varying frequency and periods of remission. Eczema is also known as atopic eczema, or atopic dermatitis (eczema).
The diagnosis of eczema is based on patient history and clinical/physical examination. Features to consider when making a diagnosis are summarized in the following tables.
American Academy of Dermatology[1] |
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Diagnostic features for eczema |
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Essential features Must be present |
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Important features Seen in most cases, adding support to the diagnosis |
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Associated features Suggest the diagnosis but are too nonspecific to be used for defining or detecting eczema for research studies |
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Exclusionary conditions A diagnosis of eczema depends upon excluding other conditions |
See table “Differential diagnosis of eczema” below |
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Hanifin and Rajka Criteria for Atopic Dermatitis [5] |
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Major criteria (must have 3) |
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Minor criteria (must have 3) |
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UK working party diagnostic criteria for eczema [6] * |
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Itchy skin condition (required) |
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Three of the following: |
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*These criteria were designed for use in research. They cannot be applied to young children
The diagnosis of eczema depends on excluding other skin conditions that may show similar features. Other diagnoses should be considered particularly when there is an atypical presentation, associated failure to thrive or inadequate response to treatment.
Differential diagnosis of eczema (not exhaustive) |
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Other inflammatory dermatoses |
Seborrhoeic dermatitis, psoriasis, contact allergy or irritation, pompholyx, napkin dermatitis, nummular eczema, lichen simplex, pityriasis lichenoides acuta and chronica, pityriasis alba |
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Ichthyoses |
Ichthyosis vulgaris, autosomal recessive congenital ichthyosis, X-linked ichthyosis, Netherton syndrome |
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Infections and infestations |
Scabies, tinea corporis, pityriasis versicolor, pityriasis rosea, HIV |
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Immunodeficiencies |
Severe combined immunodeficiency, Omenn syndrome, hyper-IgE syndrome, Wiskott-Aldrich syndrome, IPEX syndrome |
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Immunological disorders |
Dermatitis herpetiformis, juvenile dermatomyositis, graft-vs-host disease |
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Malignancies |
Cutaneous T-cell lymphoma (mycosis fungoides) |
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Metabolic disorders |
Zinc deficiency, pyridoxine deficiency, biotin deficiency, niacin deficiency, phenylketonuria, cystic fibrosis, neutral lipid storage disease |
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Other |
Urticaria pigmentosa, Epidermolysis bullosa pruriginosa |
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Infantile seborrhoeic dermatitis is often mistaken for eczema. However it is not pruritic, and causes cradle cap and moist red areas in the skin folds. It tends to improve after the age of 6 months.
Assessment requires a careful history and physical examination.
Eczema is associated with an increased risk of immediate hypersensitivity reactions to food proteins. Children with a history of immediate reactions to food should be assessed and managed accordingly. [7]
History should cover:
Underuse of topical treatments is a common cause of treatment failure in eczema.
History should address:
Formal measures of eczema severity may be used eg CDLQI, POEMS.
The examination should include:
Formal measures of eczema may be used eg SCORAD, EASI.
In some instances investigations may be needed to confirm the diagnosis of eczema and rule out other diagnoses.
Holistic assessment (taken from NICE guidelines 2007 [2]) |
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Skin and physical severity |
Impact on quality of life and psychosocial wellbeing |
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Clear |
Normal skin, no evidence of active eczema |
Clear |
No impact on quality of life |
Mild |
Areas of dry skin, infrequent itching (with or without small areas of redness) |
Mild |
Little impact on everyday activities, sleep and psychosocial wellbeing |
Moderate |
Areas of dry skin, frequent itching, redness (with or without excoriation and localized skin thickening) |
Moderate |
Moderate impact on everyday activities and psychosocial wellbeing, frequently disturbed sleep |
Severe |
Widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation) |
Severe |
Severe limitation of everyday activities and psychosocial impact, nightly loss of sleep |
The overall management of eczema should be based on clinical features, psychosocial impact, and take into account the cultural practices and beliefs of the child and family.
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