Synopsis
Diagnose and grade childhood atopic eczema, teach families safe age- and site-specific topical treatment, recognise infection and allergy signals, and protect sleep, growth, education and wellbeing.
- Atopic eczema is an itchy relapsing inflammatory disorder: itch is essential, while dryness, excoriation, sleep loss and age-specific distribution support the diagnosis.
- Infants often have cheek, scalp and extensor disease with relative napkin sparing; mobile children increasingly develop flexural, hand, ankle and eyelid eczema.
- In brown or black skin, active eczema may look violaceous, grey, deep brown or follicular rather than bright red; warmth, texture, swelling and excoriation show activity.
- Grade severity at the worst site and ask separately about night waking, mood, school or nursery, because visible area and life impact do not always match.
- First-line maintenance is liberal unperfumed leave-on emollient used every day and as a soap substitute, with a written flare plan and fire-safety advice.
- Match topical corticosteroid potency to severity and site: mild for mild disease, moderate for moderate disease and potent for severe disease, using extra caution on face and folds.
- On face and neck use mild potency routinely; a clinician may prescribe moderate potency for only 3–5 days during a severe flare, while axillae and groin need short 7–14-day courses.
- Topical calcineurin inhibitors are specialist-led second-line options from age 2 years when steroid adverse effects are a significant concern, especially at vulnerable sites.
- Crust and weeping may reflect inflammation rather than bacterial infection; systemic illness, rapid worsening and infection extent determine whether antimicrobial treatment is needed.
- Do not start broad food panels or exclusion diets for eczema alone; investigate allergy when there is a reproducible immediate reaction or moderate-to-severe disease with growth or gastrointestinal concern.
Key red flags
Painful monomorphic blisters or punched-out erosions, periocular disease, fever or lethargy, rapidly spreading cellulitis, poor feeding or dehydration, extensive skin failure, growth faltering, recurrent deep infection, treatment toxicity or a diagnosis that remains uncertain requires urgent specialist review.
Painful clusters of similar vesicles evolve into sharply punched-out erosions and may disseminate with fever; periocular involvement threatens vision.
Investigation priorities
Confirm itchy age-patterned eczema and quantify skin and life impact.
Management branches
Atopic eczema is diagnosed at any severity.
- Choose an acceptable fragrance-free leave-on emollient, prescribe a quantity sufficient for whole-body daily use and use it instead of soap and detergent washes.
- Demonstrate smooth application in the direction of hair growth, decant tubs with a clean spoon or use a pump, and provide bedding and clothing fire-safety advice.
- Create a written site-specific flare plan, continue emollient when skin is clear and review acceptability because the best formulation is the one used consistently.
Itch, inflammation, excoriation or sleep disruption signals an active flare.
- Apply prescribed mild steroid to mild eczema, moderate steroid to moderate eczema and potent steroid to severe eczema once daily unless the product plan states otherwise, treating active skin until controlled.
- Use mild potency on face and neck, with clinician-directed moderate potency for only 3–5 days in a severe flare; restrict axilla and groin treatment to mild or moderate potency for 7–14 days.
- If correctly used treatment fails after 7–14 days, reassess diagnosis, infection, adherence and contact allergy before increasing potency;
Key medicines
Unperfumed leave-on emollientApply generously to dry skin at least twice daily and whenever needed, including when eczema is clear; use a prescribed quantity appropriate to body size and wash with an emollient soap substitute rather than detergent cleanser.Ointments can be slippery and occlusive, creams can sting because of preservatives, and all paraffin-containing or paraffin-free emollient residue on clothing and bedding increases fire intensity; keep away from flames and smoking and wash fabrics regularly.
Topical corticosteroidApply a fingertip-unit-calculated thin layer to active eczema once daily unless the specific product directs otherwise: mild potency for mild, moderate for moderate and potent for severe disease, with the site and age restrictions in the written plan.Use mild potency on face and neck except a 3–5-day clinician-directed moderate course for severe flare; use mild or moderate in folds for 7–14 days; potent steroid under 12 months or very potent steroid at any child age requires specialist direction. Avoid untreated HSV and monitor atrophy and growth with repeated high-potency exposure.