This document incorporates and summarises guidelines recently published by the American Academy of Dermatology  and the British Association of Dermatologists . It is relevant to the treatment of eczema in New Zealand.
Read these guidelines in association with:
- Guidelines for the management of adult eczema
- Guidelines for the outpatient management of childhood eczema
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).
- Onset occurs mostly between 3 and 6 months, with about 60% developing the condition before 1 year and 90% by 5 years of age.
- Most patients have elevated serum immunoglobulin (IgE) levels and a personal or immediate family history of atopy (type I allergies, allergic rhinitis, and asthma).
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.
|Diagnostic features for eczema|
Must be present
Seen in most cases, adding support to the diagnosis
Suggest the diagnosis but are too nonspecific to be used for defining or detecting eczema for research studies
A diagnosis of eczema depends upon excluding other conditions
|See table “Differential diagnosis of eczema” below|
|Hanifin and Rajka Criteria for Atopic Dermatitis |
(must have 3)
(must have 3)
|UK working party diagnostic criteria for eczema  *|
|Itchy skin condition (required)|
|Three of the following:||
*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)|
|Other inflammatory dermatoses||Seborrhoeic dermatitis, psoriasis, contact allergy or irritation, pompholyx, napkin dermatitis, nummular eczema, lichen simplex, pityriasis lichenoides acuta and chronica, pityriasis alba|
|Ichthyoses||Ichthyosis vulgaris, autosomal recessive congenital ichthyosis, X-linked ichthyosis, Netherton syndrome|
|Infections and infestations||Scabies, tinea corporis, pityriasis versicolor, pityriasis rosea, HIV|
|Immunodeficiencies||Severe combined immunodeficiency, Omenn syndrome, hyper-IgE syndrome, Wiskott-Aldrich syndrome, IPEX syndrome|
|Immunological disorders||Dermatitis herpetiformis, juvenile dermatomyositis, graft-vs-host disease|
|Malignancies||Cutaneous T-cell lymphoma (mycosis fungoides)|
|Metabolic disorders||Zinc deficiency, pyridoxine deficiency, biotin deficiency, niacin deficiency, phenylketonuria, cystic fibrosis, neutral lipid storage disease|
|Other||Urticaria pigmentosa, Epidermolysis bullosa pruriginosa|
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.
Identification of triggers
- Irritants eg soaps and detergents (including shampoo, bubble bath, washing up liquid), chlorinated swimming pools, sodium lauryl sulphate-containing emollients
- Skin infections: Staphylococcus aureus, Streptococcus pyogenes, herpes simplex (eczema herpeticum), molluscum contagiosum
- Contact allergens
- Food and inhalant triggers
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. 
Assessment of current and previous treatments
History should cover:
- Bathing/showering frequency
- Use of soap, soap-free cleansers, shampoos
- Use of bath additives
- Emollient/moisturiser—frequency of application, quantity used per week
- Topical steroids—types, sites of application, quantity used per week
- Any adverse reaction to topical agents eg stinging
- Antihistamine, antibiotic use
Underuse of topical treatments is a common cause of treatment failure in eczema.
Impact of eczema
History should address:
- Psychosocial impact
- Frequency of skin infections
- Frequency of days off school/activities
Formal measures of eczema severity may be used eg CDLQI, POEMS.
The examination should include:
- Assessment for diagnostic features of eczema or other diagnoses
- Assessment of extent and severity of eczema
- Assessment for clinical evidence of secondary infection
- Growth and development—regular monitoring of height and weight is recommended for all children with moderate to severe disease
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.
|Skin and physical severity||Impact on quality of life and psychosocial wellbeing|
|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.