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Eczema (Atopic Dermatitis)

NICE guideline [CG57] Atopic eczema in under 12s: diagnosis and management. Last updated: Jun 2023. NICE CKS Eczema - atopic. Last revised: Mar 2025.

Guidelines

Clinical Diagnosis.

Diagnose eczema if there is:
  • Itchy skin, AND
  • ≥3 of the following:
    • Onset <2 y/o (but should not be used in <4 y/o)
    • Visible flexural eczema involving the skin creases (or in ≤18 months: visible eczema on the cheeks and/or extensor areas)
    • Personal history of flexural eczema (or in ≤18 months: history of eczema on the cheeks and/or extensor areas)
    • Personal history of dry skin in the last 12 months.
    • Personal history of asthma or allergic rhinitis (or in <4 y/o: family history of atopic disease in a first-degree relative)
 
 

NICE:  Note that these criteria apply to all ages, social classes, and ethnic groups. However, in children of Asian, black Caribbean, and black African ethnic groups, atopic eczema can affect the extensor surfaces rather than the flexures, and discoid (circular) or follicular (around the hair follicles) patterns may be more common.

The following categorisation is important in guiding management:
 
Category Appearance Psychological impact
Mild
  • Dry skin
  • Infrequent itching
  • +/- Small areas of redness
 Little impact on everyday activities, sleep and psychosocial well-being
Moderate
  • Dry skin
  • Frequent itching
  • Redness +/- excoriation and skin thickening
 Moderate impact on everyday activities, sleep and psychosocial well-being, and frequently disturbed sleep
Severe Widespread areas of
  • Dry skin
  • Incessant itching
  • Redness +/- excoriation, extensive skin thickening, bleeding, oozing, cracking, alteration of pigmentation
 Severe limitations of everyday activities and psychosocial functioning, and loss of sleep every night
Infected
  • Weeping, or
  • Crusted, or
  • Pustules, or
  • Fever / malaise
 n/a
 
 

It is also important to assess the psychological impact of atopic eczema on the patient.

Management approach is based on the severity category (see above).

Stepped treatment options for atopic eczema produced NICE (refined):
 

Moderate eczema

Moderate eczema

Severe eczema
Emollients Emollients Emollients
Mild potency topical corticosteroids (e.g. hydrocortisone 1%) Moderate potency topical corticosteroids* (e.g. betamethasone valerate 0.025% or clobetasone butyrate 0.05%) Potent topical corticosteroids* (e.g. betamethasone valerate 0.025% or clobetasone butyrate 0.05%)
n/a Topical calcineurin inhibitors (tacrolimus or pimecrolimus)* Topical calcineurin inhibitors (tacrolimus or pimecrolimus)*
n/a Bandages** Bandages**
n/a n/a Phototherapy**
n/a n/a Systemic therapy (e.g. oral corticosteroid, cyclosporin, azathioprine)**
* For delicate areas (e.g. face and flexures), start with a corticosteroid that is one potency class lower and only step up if ineffective (i.e. start with mild potency in moderate eczema, and moderate potency in severe eczema).

** Usually only prescribed by a specialist (e.g. GP with a specialist interest in dermatology, a dermatologist, or a paediatrician).

The below sections restructure the management of each eczema severity into 1) flare management and 2) maintenance therapy.
 

  • Regular emollient use (generous amount to be used 4 times daily on the entire body), even when symptoms are controlled
  • Flare: consider mild topical corticosteroid (e.g. hydrocortisone 1%)
    • To be continued for 48 hours after flare is controlled

Active follow up is rarely required for mild eczema, unless the person or carer requests it.

  • Moderately potent topical corticosteroid (e.g. betamethasone valerate 0.025% or clobetasone butyrate 0.05%)
    • To be continued for 48 hours after flare is controlled
    • For delicate areas of skin (face and flexures): consider starting with a mild potency topical corticosteroid (e.g. hydrocortisone 1%) and only increase to moderate potency if necessary and aim for maximum of 5 days use
  • Continue emollients (but apply at different times from the steroid)
  • Consider localised medicated dressings / dry bandages with emollients and topical corticosteroid for 7-14 days
    • Only to be used by a trained healthcare professional

If severe itch / urticaria: consider 1 month trial of non-sedating antihistamine (e.g. cetirizine, loratadine, fexofenadine)

  • Regular emollient use (generous amount to be used 4 times daily on the entire body), even when symptoms are controlled
  • Consider preventive treatment
    • 1st line: topical corticosteroid as ' step down approach' or intermittent treatment'
    • 2nd line: topical calcineurin inhibitors (tacrolimus, pimecrolimus)
      • Only to be prescribed by secondary care
      • Only used in >2 y/o
  • Consider localised medicated dressings / dry bandages with emollients to treat areas of chronic lichenified skin

  • Potent topical corticosteroid (e.g. betamethasone valerate 0.1%)
    • To be continued for 48 hours after flare is controlled
    • For delicate areas of skin (face and flexures): consider starting with a moderate potency topical corticosteroid (e.g. betamethasone valerate 0.025%, clobetasone butyrate 0.05%) and only increase to moderate potency if necessary and aim for maximum of 5 days use
  • Continue emollients (but apply at different times from the steroid)
  • Consider localised medicated dressings / dry bandages with emollients and topical corticosteroid for 7-14 days
    • Only to be used by a trained healthcare professional

If severe itch / urticaria
  • Consider 1 month trial of non-sedating antihistamine (e.g. cetirizine, loratadine, fexofenadine)
  • If itching is affecting sleep: consider short course (maximum 2 weeks) of sedating antihistamine (e.g. chlorpheniramine)
 
 

Do not use potent corticosteroids in children under 12 months old, or very potent corticosteroids in children of any age, without specialist dermatological advice

  • Regular emollient use (generous amount to be used 4 times daily on the entire body), even when symptoms are controlled
  • Consider preventive treatment
    • 1st line: topical corticosteroid as ' step down approach' or ' intermittent treatment'
    • 2nd line: topical calcineurin inhibitors (tacrolimus, pimecrolimus)
      • Only to be prescribed by secondary care
      • Only used in >2 y/o
  • Consider localised medicated dressings / dry bandages with emollients to treat areas of chronic lichenified skin

If causing psychological distress
  • Consider short course of oral prednisolone 30mg once daily for 1 week

If everything failed from above, consider:
  • Phototherapy
  • Systemic immunosuppressants (e.g. cyclosporin, azathioprine)

Admission to hospital if eczema herpeticum is suspected

DO NOT routinely offer topical / oral antibiotic for secondary bacterial infection of eczema, if systemically well:
  • If antibiotic is offered, 1st line: flucloxacillin (alternative: clarithromycin)
  • For localised infection: consider topical fusidic acid

Episodes of infected eczema usually co-exist with a flare and will require concomitant treatment as described above.

 

Dry bandages and medicated dressings (including wet wrap therapy) should NOT be used to treat infected atopic eczema.

References

Author: Adams Lau
Reviewre:
Last edited: 13/07/25