How should atopic eczema be managed?

Atopic eczema is rare in newborn infants and usually starts during the first months of life. In most children it disappears as they become older. In others it recurs or becomes chronic. A common pattern is mild chronic eczema with repeated flare-ups of acute eczema. Therefore, both the child and family need ongoing counselling and support as the condition may last for years.

Unless the eczema is mild, the child should be referred to a skin clinic at a hospital, if possible, for the management of acute eczema and the planning of management for chronic eczema. Specific management consists of the following:

  1. Local management of the skin is most important in atopic eczema. Liberal amounts of emulsifying creams (moisturizing creams or emollients), such a ‘aqueous cream’, are used in acute eczema and emulsifying ointments, such as ‘HEB’ in chronic eczema. Emulsifying creams and ointments are used as first line treatment to prevent the skin from drying out. This helps to prevent inflammation. Emulsifying creams or ointments should be applied at least twice a day.
  2. For mild or moderate eczema, 1% hydrocortisone in an emulsifying cream or ointment (emollients) should be applied twice daily. Stronger steroids (betamethasone) can be used on the trunk and limbs if 1% hydrocortisone fails to control the rash in 2 to 3 days. Do not use strong steroids for longer than one week without specialist advice. Do not use strong steroids on the face. Oral steroids must be avoided. The need for steroids is reduced if emulsifying cream or ointment is used to protect the skin. Many children with mild eczema can be adequately managed with regular use of emulsifying cream or ointment alone.
  3. 5% coal tar in emulsifying ointment is used on patches of chronic eczema.
  4. If secondary bacterial infection (impetigo) is present, povidone iodine (Betadine) cream or ointment dressings are applied for 3 to 5 days. An oral antibiotic may be needed with widespread infection.
  5. An oral antihistamine can be given for the itch and to provide some sedation in acute eczema. Local antihistamine creams are of no help. It is very difficult to stop small children from scratching. Unfortunately, scratching causes further itching and may introduce secondary bacterial infection. Gloves or socks over the hands may reduce scratching. Do not let the child get too warm as this makes itching worse. Keep the nails short.
  6. The child should wash daily with aqueous cream instead of soap. Do not use soaps, shampoos, bubble baths or washing detergents as they often make the rash worse. Showers are better than baths. Aqueous cream or emulsifying ointment (or petroleum jelly) should be applied every day immediately after washing and drying.
  7. Removing specific items from the diet may be useful in young infants but is less helpful in older children. Encourage breastfeeding.
  8. Do not let the child overdress and get too hot. Avoid wool or nylon next to the skin. Cotton clothing is best.
  9. Avoid people with cold sores, as secondary herpes virus infection is dangerous in children with eczema.
  10. If the acute eczema is not much improved after a week of treatment, refer to a specialist skin clinic.

Emulsifying cream or ointment, with or without 1% hydrocortisone, is most important in treating eczema.

If possible, wet wraps should be used at night to manage acute eczema. Wet wraps are stocking bandages (Stockinette) that have been moistened with warm water and covered in generous amounts of emulsifying ointment or aqueous cream. The wet wrap is placed over the skin where steroid has been applied. It ensures deep penetration of the steroid, and rehydrates the skin, lessens inflammation, reduces itching and discomfort and hastens healing. Wet wraps alone reduce the need for local steroids.

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