|Home | About | Journals | Submit | Contact Us | Français|
Atopic eczema affects one in five children in the United Kingdom1 and accounts for 1 in 30 consultations in community care.2 Recent data suggest that impaired skin barrier function is a major causative factor.3 4 There may be considerable physical and emotional morbidity for the child and the parents or carers, particularly if the disease is poorly controlled.5 Yet most healthcare professionals receive little or no relevant training in dermatology,6 and lack of knowledge, confusion, and anxiety about many of the available treatments are widespread among parents.5 7 This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) on how to manage atopic eczema in children from birth up to the age of 12 years.8
NICE recommendations are based on systematic reviews of the best available evidence. When minimal evidence is available, a range of consensus techniques is used to develop recommendations. In this summary, recommendations derived primarily from consensus techniques are indicated with an asterisk (*).
Itching plus three or more of:
If any of the following apply:
If used correctly, the structured approach recommended in this guidance should allow improved quality of care and more cost effective clinical management of atopic eczema. The approach requires an initial investment in time to assess the child’s atopic eczema adequately and discuss parental anxieties about treatments, emphasising that the benefits of topical corticosteroids outweigh possible harms. Written care plans should cover treatment of flares and episodes of infected eczema to educate parents on when topical corticosteroids (and other treatments) are appropriate. This investment should, however, lead to longer term benefits, empowering children with atopic eczema and their parents or carers to take control of management, and potentially reducing the need for frequent monitoring and thus the workload of healthcare professionals.
To support implementation, NICE and the guideline development group have developed a version of the guidance (available from December 2007 at www.nice.org.uk/CG057PublicInfoEnglish) that can be given to children with atopic eczema and their parents or carers).
A study conducted in the United Kingdom in 2003 reported a lifetime prevalence of atopic eczema in 12 year olds of 23%.1 Similar lifetime prevalence figures were reported in two other studies conducted in the United Kingdom (20% in children aged 3-11 yearsw1 and 25% in children aged 8 yearsw2), although a third study reported a lifetime prevalence of 41% in children aged 10 years.w3 Despite the frequency of consultations for eczema in community care (dermatological conditions account for 15% of such consultations, of which 22% involve eczema2), general practitioners lack dermatological knowledge and training.4 w4
The aim of the new guidance is to provide a framework for healthcare professionals to empower children with atopic eczema and their parents or carers to manage the condition effectively, thus alleviating the negative impact on their quality of life. The guidance encompasses education and information about topical treatments, including topical corticosteroids, which are currently a source of confusion and anxiety for many parents and limit adherence to treatment.3 5 w5
Recent studies have linked ichthyosis vulgaris, the commonest inherited type of dry skin, to a high risk of developing atopic eczema, which may be severe and persistent.3 4 This supports the belief that inheritance of genetic traits causing impaired skin barrier function is a major factor in the development of atopic eczema. Strategies to improve skin barrier function, such as reduction of irritants and the use of emollients, as recommended in the guidance, are vital for successful treatment.
The guidance was developed by the National Collaborating Centre for Women’s and Children’s Health in accordance with NICE guideline development methods (see www.nice.org.uk/page.aspx?o=114219). The collaborating centre established a guideline development group consisting of healthcare professionals and patient and carer representatives, with experts in guideline methodology from the collaborating centre. The guideline development group identified and appraised clinical effectiveness evidence and evaluated cost effectiveness of interventions where possible. Stakeholder organisations were invited to comment on a draft of the guideline that was subsequently revised to take account of comments received.
NICE has produced four different versions of the guideline: a full version containing all the evidence and the recommendations; a quick reference guide; a version known as the “NICE guideline” that lists the recommendations; and a version for patients and the public. All these versions are available from the NICE website (www.nice.org.uk/CG057). Future updates of the guidance will be produced as part of the NICE guideline development programme.w6
This is one of a series of BMJ summaries of new guidelines, which are based on the best available evidence; they will highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
Contributors: SL-J and MAM wrote the initial draft of the article using material produced collectively by the entire guideline development group and contributed to its revision and the final draft, having received feedback from every member of the group. MAM established the group and was project director. SL-J chaired the group.
Funding: The National Collaborating Centre for Women’s and Children’s Health was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.
Competing interests: SL-J has received funding from pharmaceutical companies (for advisory services, conference expenses, lecture fees, course sponsorship, and research), the British National Formulary (for reviewing treatments), the Primary Care Dermatology Society (lecture fees), the Anonymous Trust, the British Skin Foundation, and EastRen Research (research funding); she is a trustee of the British Skin Foundation and co-holder of copyright for quality of life questionnaires (she abstained from the guideline development group’s decision making on quality of life questionnaires). CC holds shares in GlaxoSmithKline and Shire and has received funding from pharmaceutical companies and the Royal Pharmaceutical Society of Great Britain (for consultancy and medical writing services). MC holds shares in York Pharma and Strakan Pharmaceuticals and has received funding from pharmaceutical companies (for consultancy, conference expenses, and research). AH has been commissioned to write for MIMS Dermatology. SL has received funding from pharmaceutical companies (for conference expenses, lecture fees, and course sponsorship) and is a member of the National Eczema Society and of the advisory group for the All Party Parliamentary Group on Skin. AR holds shares in the Boots group, is a member of the East Midlands Regional Funding Committee for the Research for Patient Benefit Programme of the National Institute for Health Research and is involved in running the Nottingham Support Group for Carers of Children with Eczema, which has been invited to participate in research for pharmaceutical companies. JR holds shares in Reckitt Benckiser and has received funding from pharmaceutical companies (for development of educational tools). SW is an employee of the National Eczema Society, which receives funding from pharmaceutical companies, and has received funding to write about trigger factors in eczema.
Provenance and peer review: Commissioned; not externally peer reviewed.