Objectives The Royal College of Paediatrics and Child Health (RCPCH) Science and Research Department was commissioned by the Department of Health to develop national care pathways for children with allergies. The eczema pathway focuses on defining the competences to improve the equity of care received by children with eczema.
Method The eczema pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence. The pathway was reviewed by a broad group of stakeholders including paediatricians, allergists, dermatologists, specialist nurses, dietician, patients' representatives and approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee. It was also reviewed by a wide range of stakeholders.
Results The results are presented in three sections: the evidence review, mapping and the core knowledge document. The various entry points to the ideal pathway of care are defined from self-care through to follow-up. There is considerable emphasis on good skin care and when allergy problems should be dealt with. The pathway algorithm and associated competences can be downloaded from http://www.rcpch.ac.uk/allergy/eczema.
Conclusions Effective eczema management is holistic and encompasses an assessment of severity and impact on quality of life, treatment of the inflamed epidermal skin barrier, recognition and treatment of infection and assessment and management of environmental and allergy triggers. Patient and family education which seeks to maximise understanding and concordance with treatment is also important in all children with eczema.
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Atopic eczema (atopic dermatitis) is an itchy inflammatory skin condition with skin creases (flexures), characterised by poorly demarcated erythema (redness) accompanied by surface change such as swelling (oedema), scratch marks (excoriations) and sometimes weeping in the acute stage and skin thickening (lichenification) in the chronic stage.1 Initial consensus-based criteria were useful in listing the clinical features of eczema,2 and these were later refined into a list of reliable and valid discriminators (table 1).3 4 Healthcare professionals should also be aware that in Asian, African and African-Caribbean children, atopic eczema may present differently. It can cause skin darkening as opposed to skin reddening (erythema) and can affect the extensor surfaces rather than the flexures. Discoid (circular) or follicular (around hair follicles) patterns of eczema may also be more common as well as gross thickening (lichenification) of the skin.5 The cellular mechanisms of eczema have been reviewed elsewhere.6
Although frequently referred to as having ‘atopic’ eczema, some children with the clinical phenotype do not have demonstrable immunoglobulin (IgE)-mediated sensitivity to allergens,7 leading the World Allergy Organization to propose that the term ‘eczema’ alone is used to denote the clinical phenotype which may or not be atopic. While the presence or absence of atopy does not help our clinical predictive ability to diagnose eczema,8 9 it does tend to correlate with eczema severity, with atopic sensitisation being more prevalent in patients with more severe disruption of their skin barrier problems particularly in infants with atopic mechanisms contributing to skin inflammation in some but not all patients.7
Disease severity and quality of life
Most cases of childhood eczema in any given community are mild (84%) with infrequent flares and minimal disruption to sleep and daily activities. Moderate and severe eczema, which affect 14% and 2% of the population, respectively, may significantly impact quality of life and psychosocial function.10 Specific aspects affected include itch and its associated sleep loss (causing considerable family disturbance), social stigmatisation, the need for special clothing and bedding, avoidance of activities (eg, swimming) and the need for frequent applications of topical treatments and visits to healthcare professionals.11 Several cost of illness studies suggest a high economic burden for eczema,12 with overall costs comparable to those of asthma.13 Family stress related to the care of children with moderate or severe eczema may be significantly greater than that of type 1 diabetes, mainly owing to sleep deprivation, employment loss, time to care for eczema and financial costs.14
A holistic approach should be taken into account when assessing eczema severity which includes an assessment of skin severity together with its impact on a child's sleep, everyday activities and psychosocial wellbeing. (table 3) There is not necessarily a direct relationship between the severity of eczema and its impact n quality of life. Although several disease severity scales exist, only three (SCORing atopic dermatitis (SCORAD), eczema area and severity index (EASI) and Patient Oriented Eczema Measure (POEM)) have been shown to perform reasonably well to standard psychometric scale requirements.15 The POEM is the only one that has been derived from patients for patients.16 Validated tools for assessing quality of life in infants and children with eczema include the Children's Dermatology Life Quality Index,17 Infant's Dermatitis Quality of Life index18 and Dermatitis Family Impact Questionnaire.19 20
The International Study of Asthma and Allergies in Childhood (ISAAC) has shown that eczema symptom prevalence varies from around 2% to 20% around the world, with the UK, Scandinavia and Australia having some of the highest rates.20 21 ISAAC time trends data suggest that eczema has been increasing worldwide over the past 10 years, especially in developing countries and in younger children.22 The reasons for such a rapid increase are still unclear, but they cannot be explained by genetics, though epigenetic events may be involved.
Natural history and aetiology
Eczema commonly starts in the first years of life23 with onset before the age of 2 years in 80% of cases. Adult onset eczema in hospital-based studies occurs in only 10% of patients.24 Studies of representative populations suggest that around 60% of childhood cases of eczema are free of symptoms by early adolescence,23 25 although up to 50% may recur in adulthood.26 Approximately one-third of patients with eczema persist with eczema into adult life. Risk factors for eczema persistence are disease of early onset, severe widespread disease in infancy, concomitant asthma or hay fever and a family history of eczema.23
Patients with eczema are at higher risk of developing asthma. Sensitisation to food and inhalant allergens in infancy appears to predict the onset of allergic airways disease in childhood and asthma persistence at age of 20 years, raising the concept of ‘the allergic or atopic march’, an observed progression of allergic symptoms in some but not all patients.27,–,29 In the German Multicentre Allergy Study all participants with eczema and IgE sensitisation to at least one food allergen at the age of 12 months had allergic airways disease by 5 years of age.30 Coexistence of early onset wheezing with early onset eczema in this study conferred a greater risk for asthma at 7 years than in those infants with eczema but no history of early wheeze, suggesting co-manifestation of two phenotypes at an early age rather than an allergic march.31 32
There is good evidence to suggest that genetic factors are an important predisposition to eczema.33 Twin studies34 have shown a much higher concordance for monozygotic (85%) than for dizygotic twins (21%). The most consistent genetic markers for eczema are those coding for filaggrin protein, a hygroscopic protein that is key to helping to maintain the barrier function of the skin and which may explain much of the associated dryness of eczema.35
Environmental factors are also likely to be critical in determining disease expression in eczema given the large increase of disease prevalence over a short time,22 the positive social class gradient32 and the fact that migrants coming from a country with low disease prevalence seem to develop higher rates in their adopted country.36 The observed inverse association between the prevalence of eczema and family size, has led to the ‘hygiene hypothesis’.37 The possible link between reduced microbial or helminth exposure in modern society and increased eczema is a complex one which has been reviewed elsewhere.38
Bacterial infections of the skin are more common in patients with eczema and play an integral role in eczema pathogenesis.39 Damage to the epidermal skin barrier from inflammation and scratching allows bacterial colonisation with Staphylococcus aureus in 90% of patients with eczema compared with 30% of unaffected individuals.
Viral infections of the skin are also higher in patients with eczema. Eczema herpeticum is an uncommon generalised (or locally widespread) vesicular eruption caused by the herpes simplex virus. It is important to recognise and initiate hospital treatment immediately for eczema herpeticum as this can cause significant mortality if left untreated.
Trigger factors for eczema
For those with established eczema, a plethora of other potential environmental factors for exacerbating eczema have been suggested including exposure to irritants (eg, soaps, shampoos), rough clothing (eg, wool), contact allergens, food and inhalant allergens, microbes and climatic factors.39 40 Inhalant allergens (eg, house dust mite, pollens and animal dander) can trigger eczema exacerbations in allergic patients.41
Hospital-based studies have shown the presence of food allergy in approximately 30% of children with moderate to severe eczema, proven by blinded oral provocation challenge testing.42,–,50 Most common food allergens are cows' milk, hens' eggs, nuts, soya, wheat and fish. The risk is greatest in infants and young children with eczema, whose disease is of early onset (within the first 12 months).51,–,53 In infants with mild intermittent eczema and in children whose eczema developed after their first birthday, the likelihood of food allergy is much reduced.
The pathway method is described separately in this supplement.54
A total of 625 titles and abstracts were screened by the project manager and the Eczema Working Group Chair (figure 1). Thirty-six systematic reviews and/or primary papers and nine guidelines were identified for appraisal; handsearching the reference lists of appraised papers identified a further five papers. The critical appraisal resulted in the inclusion of 13 systematic reviews and/or primary papers and seven clinical practice guidelines.
The evidence review found that atopic dermatitis is frequently the first manifestation of an atopic diathesis. Between 30% and 50% of children with atopic dermatitis will eventually develop allergic rhinitis or asthma later in childhood.27 An additional study found that one in three children with eczema later develop asthma.28 Eczematous reactions to food can only be diagnosed by taking into account the patient's history, the degree of sensitisation and the clinical relevance of the sensitisation.55 Oral food challenge tests are frequently required to obtain an accurate diagnosis of food allergy. There is little benefit in adopting exclusion diets in unselected cases of atopic eczema but it may be appropriate to trial if there is a clinical history of reactions to foods,56 or a clinical history and allergy tests that strongly support the diagnosis of food allergy. Infants with severe atopic eczema are more likely overall to benefit from amino acid-based or extensively hydrolysed cows' milk formula, particularly when associated with symptoms of gut dysmotility or failure to thrive.57
The best patient eczema severity measures were found to be SCORAD, EASI and POEM.15 In addition to measuring skin manifestations, quality of life should be assessed and psychological interventions were found to significantly ameliorate eczema severity, itching intensity and scratching.58
The literature clearly demonstrates that education and training of children and parents and its role in improving the regular use of emollients.59 60 Other studies indicate that written information should be given to parents and that doctors should try to improve partnership during consultations.61 In support of this the benefits of nurse-led clinics, compared with care from a doctor, were associated with increased patient satisfaction, longer consultations resulting in improved patient education and similar health outcomes. There were no studies identified comparing nurse-led and doctor-led clinics in the management of eczema.62
The national Royal College of Paediatrics and Child Health (RCPCH) care pathway can be downloaded from http://www.rcpch.ac.uk/allergy/eczema. This pathway was been developed around the competences required to diagnose and optimally manage eczema.62 64 These competences have not been assigned to specific health professionals or settings in order to encourage flexibility in service delivery. However, it is envisaged that the provision of optimal care at all NHS levels will require close liaison between different health professional groups including doctors, nurses, pharmacists and dietitians. All health professionals should have paediatric training in line with the principles outlined in the Children's National Service Framework.65
The pathways recommend the stepped approach to management,5 using emollients even when the atopic eczema is clear (table 2). Management can then be stepped up or down, according to the severity of symptoms, with the addition of the other treatments.
A total of 13/53 (25%) of invited organisations responded, providing 78 comments. All comments were reviewed by the Eczema Working Group and the pathway was approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee.
Core knowledge document
The core knowledge document for this pathway is the National Institute for Health and Clinical Excellence guideline for atopic eczema in children.5
The wide variation across the UK in the provision of care for children with allergic conditions is described elsewhere 5 Effective eczema management requires a holistic assessment of its severity and impact on the child and family's psychosocial functioning and quality of life. Severity can vary from one area of the body to another and does not need to be severe to harm a child's psychosocial well-being.
Initial management of eczema
Initial treatment should focus on repairing the skin barrier through the use of emollients for moisturising, washing and bathing. Inflamed skin requires a stepped approach to treatment, in which the potency of topical steroids used at each step is tailored to the severity of the eczema, body site and age of child.5 Topical calcineurin inhibitors are used as second line treatments, within their licensed indications, for the treatment of moderate to severe eczema.
Oral antibiotics are recommended for the treatment of obviously infected eczema (weeping, pustules, crusts, atopic eczema failing to respond to treatment, rapidly worsening atopic eczema, fever, malaise). Suspicion of secondary infection of eczema with herpes simplex virus should prompt rapid assessment and treatment. Eczema herpeticum is a medical emergency requiring same day hospital treatment and should be suspected in the presence of rapidly worsening, painful eczema, clustering of small blisters, punched out circular erosions or crusts of uniform appearance and possible fever, lethargy and distress.
Advice regarding the management of eczema should be given in verbal and written format in language that is easy to understand. Education which seeks to maximise understanding and concordance with treatment is important in all children with eczema. It is important to highlight that eczema is usually a chronic disease, and that measurement of treatment impact should include long-term measures such as number of well controlled weeks or number of disease flares prevented66 rather than short-term reduction of composite disease scores, the clinical interpretability of which can be obscure.16 This is currently lacking in many cases.
Assessment of trigger factors
A clinical history which seeks to identify trigger factors for eczema is recommended, especially when eczema is responding poorly to treatment or where there is a continuous daily requirement for potent or moderately potent steroids in an infant or young child. In the older child, the association of allergic rhinitis (hayfever) or asthma with eczema should raise the possibility of associated inhalant allergies. Treatment with a non-sedating antihistamine in patients allergic to tree or grass pollen who experience flares of eczema within the pollen season, may be beneficial. House dust mite allergy is commonly associated with eczema. However, evidence that current house dust mite reduction measures are effective in reducing eczematous inflammation is limited.67
In the young infant the association of gut symptoms with eczema or severe eczema responding poorly to topical treatments should raise the possibility of food allergy. For bottle fed infants under 6 months a 6–8 week trial of an extensively hydrolysed or amino acid formula should be offered in place of a cows' milk formula. In breastfed infants the mother should be offered a trial of an allergen-specific exclusion diet for 6 weeks, although the evidence that this is beneficial is limited.5
The overall prevalence of food allergy in infants and young children with moderate to severe eczema is 30%.42,–,50 The perceived prevalence of suspected food allergy in eczema, however, is much greater and self-imposed exclusion diets are common with up to 75% of patients trying food exclusions.68 This puts individuals at risk of nutritional deficiencies and may unnecessarily restrict their lifestyle even further. In particular, infants who are breastfed beyond 6 months without monitoring or vitamin supplementation are susceptible to vitamin D deficiency, rickets, iron deficiency, anaemia and other vitamin deficiencies. Frequently, the diagnosis of food allergy can be excluded thus allowing the child's diet to be liberated.
An accurate diagnosis of food allergy is made by interpreting the allergy tests in the face of a thorough clinical history. This requires an understanding of the different presentations of food allergy (IgE-mediated and non-IgE-mediated), natural history and performance of tests. Competences for making these assessments are defined within the pathway and we hope that they guide treatment.
Where food allergy is confirmed, specific dietary avoidance should be implemented together with an assessment of the child's nutritional requirements for any dietary restriction imposed for longer than 4 weeks. Dietary management can be an effective strategy for the treatment of eczema in children where an allergen-specific diagnosis has been confirmed.56 69 More research in this area needs to be conducted.
Conclusion and clinical implications
This eczema care pathway is designed to guide patients, carers and healthcare professionals in the optimal management of eczema in infants and children. Each step of the guideline details the appropriate competences required to make an accurate clinical diagnosis, thus enabling initiation of effective treatment for eczema. Where the appropriate competences are not available onward referral is recommended. The approach is holistic and encompasses an assessment of severity and impact on quality of life, treatment of the inflamed epidermal skin barrier, recognition and treatment of infection and assessment and management of environmental and allergic triggers.
Ms Hilary Whitworth, a PhD Student at University of Southampton, who provided assistance for the evidence review. The RCPCH Allergy Care Pathways Project Board who provided guidance and assistance. The RCPCH Clinical Standards team for their hard work on the approval process—in particular, Ms Katie Jones.
Competing interests JW: Novartis, Danone, Airsonette, Merck, Allergy Therapeutics, Phadia. Research, GSK, Astra–Zeneca, Merck, Allergy Therapeutics, ALK. TB: MSD-UK, GSK, ALK-Abello, Mead Johnson, Danone (Nutricia), Astra–Zeneca, Allergy NI, Schering Plough. CC: Stiefel, Galderma, Almirall. Conference attendance: Leo, Galderma. AL: Stiefel, GSK, Reckitt Benckiser, Dermal, Leo, Galderma. SLJ: Wyeth, Astellas, Stiefel. Chair, NICE guildeline for atopic eczema in children. CV: GlaxoSmithKline, Danone, Mead Johnson.
Provenance and peer review Commissioned; internally peer reviewed.