Synopsis
Assess childhood atopic eczema by impact and severity, restore the skin barrier with a practical emollient and anti-inflammatory plan, distinguish ordinary flares from bacterial infection and recognise eczema herpeticum before eye or systemic complications develop.
- Atopic eczema is an itchy, relapsing inflammatory skin disorder; assess sleep, school, play, family burden and psychosocial impact separately from visible extent because impact may be severe with limited rash.
- First-line maintenance is an unperfumed leave-on emollient used generously and frequently over the whole skin, with a suitable soap substitute and a product the child will actually tolerate.
- Treat active inflammation with topical corticosteroid of appropriate potency: mild for mild disease, moderate for moderate disease and potent for severe disease, modified by age, site and specialist limits.
- Apply topical corticosteroid once or twice daily only to active eczema and continue emollient; potent corticosteroid in a baby under 12 months requires specialist dermatological supervision.
- Face and neck usually need mild potency, with a short moderate-potency course only for severe flare; axillae and groin need caution because absorption and adverse effects are greater.
- Crusting, weeping, pustules and rapid worsening can reflect bacterial infection, but many non-systemically-unwell flares do not benefit from antibiotics; continue eczema treatment and reserve antimicrobials for the NICE-defined pattern.
- For a small localised non-systemic bacterial infection, topical fusidic acid 2% three times daily for 5 to 7 days is an option when an antimicrobial is judged necessary; widespread or systemic infection usually needs oral therapy selected by age and allergy.
- Painful rapidly spreading monomorphic vesicles or punched-out erosions, fever or malaise suggests eczema herpeticum and needs same-day specialist assessment and systemic aciclovir.
- Eczema herpeticum around the eye needs immediate ophthalmology involvement as well as systemic antiviral treatment; do not use topical antiviral alone.
- Persistent poor control requires review of diagnosis, quantity and technique, infection, irritants, allergy clues, treatment fear and access before escalating to wet wraps, calcineurin inhibitors, phototherapy or systemic therapy.
Key red flags
Monomorphic painful vesicles or punched-out erosions with fever suggests eczema herpeticum and needs same-day systemic antiviral treatment.
Periocular herpes lesions, painful red eye, photophobia or altered vision requires immediate ophthalmology involvement.
Rapidly spreading erythema, severe pain, fever, tachycardia or reduced responsiveness suggests cellulitis or sepsis.
A baby with widespread severe eczema, diarrhoea, infections or faltering growth may have immunodeficiency or another systemic disorder.
Repeated potent topical steroid use on face, folds or large areas raises skin and systemic adverse-effect risk.
Sleep loss, depression, school refusal or family breakdown is a treatment-escalation signal, not a cosmetic concern.
Immediate food reactions with airway, breathing or circulatory features require anaphylaxis care rather than eczema management alone.
Painful monomorphic vesicles or punched-out erosions with fever or rapid spread requires same-day antiviral assessment.
Investigation priorities
Confirm the age-patterned itchy dermatitis and document extent, intensity, sleep and quality-of-life impact.
Management branches
The child has dry atopic skin during a flare or between episodes.
- Offer unperfumed leave-on products suited to skin, season and preference and prescribe enough for frequent whole-body use.
- Replace soap and detergent cleansers, demonstrate pump or clean-spoon technique and apply gently with hair direction.
- Review tolerance, nursery or school access and paraffin fire safety and switch texture rather than abandoning barrier treatment.