Introduction
Eczema is a chronic inflammatory skin听condition听that affects 30% of children听in Australia听and causes dry, hot, itchy, red skin听
Aim
To provide evidence-based strategies for the management of Eczema (atopic dermatitis) in order to improve eczema severity and reduce the negative impact on patient and family quality of听life.听
Definition of Terms
- Eczema (atopic dermatitis): common, chronic inflammatory skin condition, presenting as generalised skin dryness and itch. Characterised by chronic dermatitis with remission and relapse with acute flares. Caused by interplay between environmental and genetic factors.
- Flares: a worsening of the eczema
- Triggers: factors that cause the eczema to flare听
- Wet dressings: dressings used in the treatment of eczema听
- Infected eczema: weeping and crusting occurs when the eczema is secondarily infected by organisms such as bacteria Staphylococcus aureus, Streptococci, Candida or viruses such as Herpes simplex and molluscum contagiosum听
Assessment
The UK Diagnostic Criteria for atopic eczema are:
- Must have itch
- Plus 3 or more of the following:
- History of involvement in skin creases
- Personal history of asthma or allergic rhinitis (or history of atopic disease in 1st degree relative if child is under 4 years of age)
- A听history of dry skin in the last year
- Onset under the age of 2 years (not used if child is under 4 years)
- Visible flexural eczema
Erythema: redness of the skin
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Discoid eczema: disc shaped, clearly demarcated eczematous patches to limbs and trunk.
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Bacterial secondary infection: Crusting, weeping, erythema, cracks, frank pus, or multiple excoriations. Increased soreness and itch.
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Assessment tools
Patient assessment should be undertaken by either a medical officer or a nurse听practitioner/听consultant鈥痶o grade the degree of eczema severity (mild,听moderate听or severe), and the presence or absence of infection.鈥 听
The type and frequency of eczema treatments depend on鈥痚czema severity鈥痑nd the鈥痯resence/absence of infection.听
Eczema severity
| 听Clear听 |
Normal skin, no evidence of active atopic eczema 听 听 听 |
| Mild | Areas of dry skin, infrequent itching (with or without small areas of redness)听 |
Moderate
| Areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening)听 |
| Severe 听 | Widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing,听cracking听and alteration of pigmentation)听 听 听 |
Management
Eczema Treatments fall into two categories -听Everyday /Trigger Avoidance听and Flaring /Acute听
1.听Everyday treatments and avoidance of triggers听
These treatments are ongoing regardless of the presence or absence of eczema.
- Avoiding environmental aggravators
- Heat - such as thick layers of clothes, hot heaters, hot cars, classrooms, hot baths, thick blankets, woolen underlays or electric blankets and hot water bottles.
- Prickly/rough听material - for example wool, sandpits, clothing tags.
- Potential Irritants - Avoid听washing machine听powders, shampoos, moisturising听products that听contain听Sodium Lauryl听Sulfate听(SLS), Benzalkonium Chloride,听Plants,听Fragrance/Perfumes and Food products.
- Regular moisturiser,听should be applied from top to toe at least twice a day even if the skin is clear of eczema to reduce the skin dryness. Apply to wet skin after bathing and reapply when skin feels dry.听
- When topical steroids are in use moisturisers should be applied directly over the steroids.听
- Examples of over the counter in pharmacy moisturisers: QV cream鈩, Cetaphil cream鈩, Kenkay cream鈩, Atoderm cr猫me鈩, Avene xeracalm鈩 cream, Dermezetm treatment cream, CeraVetm Cream Lipikar鈩 AP+M.
- Creams should be removed from the tubs onto clean paper and then taken from the paper to the skin to avoid bacterial contamination of the tub.鈥
- Avoid creams听containing听SLS, Benzalkonium Chloride, Plant,听Fragrance/Perfumes听and Food products.听
- Daily cool bath (30-32 degrees C) -听The face and head should be wet well and the skin should not be rinsed with fresh water after the bath. It is no concern if the child swallows some of the water.
- BATH OIL-non soap听(1-2听capfuls).
- SALT -听when the eczema is moderate to severe or the skin stings when the child bathes,听salt (1/3 cup per 10 litres water)听may be added.听听
- BLEACH -听when the eczema听moderate to severe听or infected听(or as recommended by healthcare professional)听add听white king听household听bleach 4% (sodium hypochlorite 4%) (12mLs per 10 litres water). 听
- All three ingredients can be added together to the bath water. If skin infection present it is preferred to not add听bath听oil.
- Consider Vitamin D oral daily supplementation for moderate to severe eczema or if the baby is breast fed. This is especially important throughout Colder/Winter months.
2.听Flaring treatments听
These treatments should be听commenced听as soon as there is a flare听(when the skin is rough听-听like sandpaper, an increase in redness听or听itch听levels), and听stopped when the symptoms are controlled and听re-started if flaring again.听As the eczema is better controlled the need for topical steroids will decrease.听
2.1 Topical steroids and anti-inflammatory creams听
Topical steroids are听required听once or twice daily until the skin is completely clear to reduce skin inflammation. They can be applied to broken and infected skin.听
- There is no requirement to use topical steroids 鈥榮paringly鈥 or for regular breaks from steroids during treatment for eczema flares. Steroids should be applied听liberally/generously followed by moisturiser. Steroid cream dosage for application should be calculated听the "鈥" method.听
- For mild facial eczema use a weaker potency (than for body) steroid such as hydrocortisone 1% twice a day as听required. These are available in cream and ointment听eg听Cortic鈩,听Sigmacort鈩. No prescription is听required.听
- For moderate facial eczema which is non-responsive to steroids (such as hydrocortisone 1%) a pimecrolimus (Elideltm鈩⑻齝ream) can be prescribed听by medical/nurse practitioner as a听non-steroid alternative听to use as a second line treatment. Can be used twice a day in sensitive areas听such as face,听eyelid听and groin.听
- For body and scalp use a stronger steroid (than the face) example听Advantan鈩⑻齩r听Elocon鈩. These are available in cream, ointment, fatty听ointment听and lotion.听
- As the eczema is better controlled the need for topical steroids will decrease.听
2.2 Moisturisers听
2.3 Bathing听
2.4 Medications 听
Antihistamines听are not routinely used for eczema unless it has been triggered by an allergic, environmental听allergens听or insect bites. They听can听assist听with the eczema itch. Use with caution听as directed by medical practitioner,听in children under 12 months of age.听
2.5 Tar creams 听
Used when the skin is听lichenified听(thickening of the skin)听or for discoid eczema. Tar creams should not be applied to the face,听groin听and flexures.鈥疶hese creams can be applied directly over the steroid creams and under the moisturiser. A听suggested compound for a听tar cream is 3% LPC in zinc听cream听(example听KenKay鈩⑻齞ual purpose cream).听No prescription necessary but require a compounding pharmacy听
2.6 Wet dressings
Used for moderate to听severe eczema听or when the children are waking from the itch.
If the wet dressings (example Tubifast鈩) are not readily available wet clothes (onesie, leggings/T Shirt) can be used instead. A dry layer of clothing may be applied over this however remove the top layer when dry and if awake. Wet dressings should only be needed for 3-5 nights.听
Wet dressings using Tubifast tm
The wet dressing/clothes regime is as follows:
- Mild eczema
- Moderate eczema
- Once to twice daily for 3 days
- Nightly until the eczema is clear and then recommence nightly if flaring
- Severe eczema
- Four times a day for 3 days only (Admission or HITH may be referred to assist during this acute phase)
- Then taper to twice daily for one week
- Then nightly until the eczema is clear and then recommence nightly if flaring.
Cool compress
- Can be used for immediate relief of itch especially to face听
- Wet a cloth (example听chux听towel听or听rediwipe) with water and plain bath oil听
- Apply cool, wet cloth to itchy areas for 5 -10 minutes, then apply a moisturiser post compressing听
- Age dependent, children should be encouraged to learn this technique rather than scratching听
- Using a thermal water spray to the itchy area is another听option听
| Wet dressings
 Cool compresses
 听 |
Management of Complications - Infected eczema听
Secondary bacterial infection
听Is a听common complication听of eczema听as the skin is not intact and thus more vulnerable to infection.听Infection can make eczema worse and more difficult to treat.鈥鼴acterial infection should be suspected if there is crusting,听weeping,听frank pus,听cracks, multiple excoriations increased soreness and itching. 听A听common听causative听bacterium听is听Staphylococcus aureus听which听is听commonly听found on听eczema听skin.听
Secondary viral infection
Is caused by herpes simplex virus (HSV) is characterized by a sudden onset of grouped, small white or clear fluid filled vesicles, satellite or "punch out" lesions, pustules, and erosions. It is often tender, painful and itchy.
NOTE: most patients with viral infected eczema, invariably also have a bacterial skin infection as well. Assess using听appropriate skin听swabs to听identify听causative organism. 听听
Other viruses that may cause the eczema to flare are molluscum contagiosum and coxsackie A6 virus (hand foot and mouth disease).
Secondary bacterial infection  听
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Secondary herpes simplex 1 infection
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The principles of managing infected eczema are:
- Remove the crusts with a wet disposable cloth (example chux or rediwipe) and gently wipe. This is best done when bathing.听
- Steroid cream can be applied over open skin and presence of infection, however FIRST remove the crusts and weeping.
Daily plain water bath adding听
- White king鈩⑻ household bleach 4% (sodium hypochlorite 4%)听to the cool bath water (30听鈥 32 degrees). The dilution should be 12听mLs听per 10 Litres of water.
- Salt can be added to decrease stinging and to help settle inflammation and itch. The dilution is 100 grams or 1/3 cup per 10 Litres of water.
- Bleach baths鈥
For bacterial infections听
- A bacterial swab may be ordered by medical / nurse practitioner to confirm infection and bacterial sensitivities or if听suspecting a multi resistant organism听e.g听MRSA听
- Oral听antibiotics听prescription may be听required听(example听cephalexin or flucloxacillin) for 5听to 10 days. 听听
For viral infections听likely caused听by HSV 听
- Prescription required for听oral听acyclovir听as soon as possible and within 48 hours of onset of symptoms. Little benefit will be realised if treatment is delayed beyond onset of symptoms听after听72 hours (unless patient is immunocompromised or has progressive clinical state)听
IV听acyclovir听may be used for severe infections, those who are systemically unwell and febrile patients and those听patients听with threatened eye involvement.
听*Urgent Ophthalmology review if the infection is near the eye(s).听
Possible investigations
Inpatient admitted, for eczema, should have bacterial skin swabs taken.听
- This swab should be collected from an open, excoriated, or crusted eczema lesion. Allowing determination of causative organism, and to identify organism resistances to assist with antimicrobial prescribing.
For patients attending the Outpatient Department,
- A skin swab should be taken from an infected eczema lesion when MRSA is suspected or to verify a bacterial organism.
- Patient and parent nasal swabs are only required for patients who are experiencing recurrent infections and boils when suspecting ongoing nasal carriage.
Viral swabs may be needed to confirm causative organism, this should be collected from the base of a fresh blister. 听
Documentation - Eczema Treatment Plan
All patients should have an Eczema Treatment Plan completed before they are discharged/go home.
See EMR smart phrase 鈥淓czema treatment plan鈥 听
Product List RCH Dermatology听
Referrals
Patients may听require听to be听seen by other specialties.听A medical referral is听required听for听Paediatrician, Allergist, RCH Dermatology/Eczema Clinic听and HITH.
| Eczema NEW clinic appointments |
Eczema Clinic Coordinator |
9345-6441 (Mon-Fri) |
| Allergy testing and advice |
Immunology or RCH Allergy Department or private allergist |
9345-6180
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Family听require听ongoing support for eczema treatment / management at home. See link for referral criteria.听 RCH HITH traffic light eczema Aug22鈥 |
Wallaby Ward Hospital in the Home (HITH) |
9345-4770听 听
Email: Wallaby.Ward@rch.org.au听 |
Medical complications听ie. FTT, low iron/vitamin D听
|
General Medicine |
9345-6180 (Mon-Fri) |
Follow up appointment recommendations
| Mild eczema |
General Practitioner |
听 |
| Moderate eczema |
General practitioner or Specialist Clinics 鈥 Eczema Clinic - NEW
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2 - 4 weeks, if improved to mild then discharge to General Practitioner |
| Severe eczema |
Specialist Clinics 鈥 Eczema Clinic - NEW
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1 - 2 weeks, then as per mild and moderate |
For further assistance the Dermatology Registrars can be paged via switchboard 9345 5522.
Allergy听
In the event of听an immediate reaction (such as urticaria and angioedema) to a food and/or severe persistent eczema in a baby,听medical /听nurse practitioner to听refer for specialist allergy evaluation.鈥
Refer to immunologist, allergist for Skin Prick Test (SPT) and dietician if food allergies are proven on SPT or听ImmunoCAP听IgE test.听
Visit ASCIA for more听information:鈥听
Parent education information
Prior to discharge discuss听the听everyday treatments 鈥 avoidance of听environmental听triggers听- overheating, rough prickly materials, and ensure regular and ongoing use of moisturisers and eczema baths.听
Give guidance on听eczema听treatment plan 听
Encourage the families to undertake the Eczema听Triggers Questionnaire听to help听identify听most likely to least likely triggers听and听E learn for education and demonstration of how to apply the topical听treatments. 听
Eczema resources
For clinical staff:听
For parents:
Evidence table
Eczema Management Evidence Table
听
Please remember to
The development of this nursing guideline was coordinated by Emma King, Nurse Practitioner听and members of听Dermatology Department听and Allergy听Department, and听approved by the Nursing Clinical Effectiveness Committee.听Reviewed and updated听by Melissa Dallinger & Danielle Paea, December听2025.鈥