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Dermatology

Atopic eczema

Atopic eczema is a chronic, relapsing, intensely itchy inflammatory skin disorder in which epidermal barrier dysfunction and immune dysregulation reinforce each other; management combines daily skin care, prompt anti-inflammatory treatment, infection recognition and escalation according to severity and life impact.

In a nutshell

Atopic eczema is a relapsing itchy inflammatory disorder driven by interacting barrier dysfunction and immune dysregulation. Diagnose clinically, assess sleep and quality of life as well as visible skin, use daily emollient plus site-appropriate anti-inflammatory treatment, avoid routine swabs and antibiotics in a well patient, and treat suspected eczema herpeticum immediately.

Classic presentation

A child with generalised xerosis and recurrent itchy flexural eczema has excoriations, sleep disturbance and an atopic history; an infant may instead have facial or extensor disease, and erythema may be subtle in darker skin.

Key points

  • CG57 diagnostic, topical-steroid and referral rules apply to children under 12 and must not be copied unlabelled into adult care.
  • Barrier dysfunction and immune inflammation reinforce each other; filaggrin variants and raised IgE are not universal.
  • Judge severity by extent, morphology, itch, sleep and quality-of-life impact, not redness or pigment change alone.
  • Use unperfumed emollient every day over the whole body; in children under 12, do not offer emollient bath additives.
  • All emollients can create a severe fabric fire risk, including paraffin-free products; avoid smoking and naked flames.
  • In children, match topical corticosteroid potency to severity and site, treat flares promptly and consider proactive 2-days-per-week treatment for frequent recurrence (see BNF).
  • Tacrolimus and pimecrolimus are second-line, not mild-disease or first-line treatment; pimecrolimus under TA82 is specifically for moderate face or neck eczema at age 2 to 16 (see BNF).
  • Do not routinely swab suspected bacterial infection at first presentation or give antibiotics to a patient who is not systemically unwell; continue emollient and topical corticosteroid.
  • Suspected eczema herpeticum needs immediate systemic aciclovir and same-day specialist assessment, with same-day ophthalmology if periocular; do not await confirmation (see BNF).
  • Phototherapy and systemic treatments are specialist-owned. Current NICE options include conventional immunosuppression, biologics and JAK inhibitors with agent-specific eligibility and safety checks.
  • There is no current comprehensive NICE adult or adolescent eczema guideline, so separate adult wording should use current BNF, technology appraisals and specialist pathways.
  • Pregnancy, breastfeeding, live-vaccine restrictions and laboratory monitoring differ by systemic agent and must be checked drug by drug (see BNF).

First-line investigation

None routinely: diagnose clinically and document physical severity, itch, sleep and quality-of-life impact; do not routinely swab a suspected bacterial flare at first presentation.

Management

Recognise emergencies

  • Rapidly worsening painful eczema with clustered vesicles or uniform punched-out erosions is eczema herpeticum until proved otherwise. Start systemic aciclovir immediately and arrange same-day dermatology assessment; periocular disease also needs same-day ophthalmology (see BNF).1,20
  • Urgently assess systemic illness, rapidly spreading infection, disproportionate pain, erythroderma or acute skin failure. Consider cellulitis, necrotising infection and sepsis rather than labelling every deterioration as an eczema flare.6,7

Diagnose and grade impact

  • For a child under 12, use the age-specific CG57 itchy-skin-plus-3 criteria, including the special site rules at 18 months or younger and the restriction that onset before age 2 is not counted in a child under 4. Adults need a separate clinical diagnosis.1,8
  • Grade each site and ask about itch, sleep, school or work, relationships and psychological impact. Consider POEM and age-appropriate quality-of-life tools; erythema may be underestimated in darker skin.1,3
  • Test for food allergy only when the history or uncontrolled moderate to severe early-childhood disease makes it plausible. A positive IgE or skin-prick test shows sensitisation, not necessarily clinical allergy.1

Build reliable topical treatment

  • Use unperfumed leave-on emollient daily over the whole body, smooth rather than rub, use an emollient or soap substitute for washing and wait several minutes between topical products. In children under 12, do not offer emollient bath additives.1,15
  • Warn that residue from any emollient can make clothing, bedding and dressings burn rapidly. Keep away from smoking and naked flames, and explain that washing does not fully remove the risk.16
  • For a child under 12, use mild potency for mild, moderate for moderate and potent for severe eczema (see BNF). Use mild on face or neck, except moderate for 3 to 5 days in a severe facial flare; limit moderate or potent treatment at axillae or groin to 7 to 14 days.1,4,14
  • Adults and adolescents need site- and severity-appropriate potency using current BNF and local formulary advice. Repeated failure should prompt checks of quantity, technique, adherence, contact allergy, infection and diagnosis rather than unstructured escalation (see BNF).4,8,14

Use steroid-sparing and wrap options correctly

  • Under TA82, tacrolimus is second-line for moderate to severe disease in adults and children at least 2 years old when maximum appropriate topical corticosteroid has failed and further use risks important harm. Pimecrolimus is second-line for moderate face or neck eczema at age 2 to 16 under the same conditions (see BNF).5,18,19
  • Whole-body wet wraps are not first-line and must be started by a trained clinician. Do not use occlusive medicated dressings or dry bandages over infected eczema; limit initial whole-body wrap plus topical corticosteroid treatment to 7 to 14 days (see BNF).1,14
  • Antihistamines do not treat eczema inflammation. In children, reserve a time-limited trial for severe itch, urticaria or major flare-related sleep disturbance and review benefit (see BNF).1,14

Manage infection and allergy selectively

  • Do not routinely swab at initial suspected bacterial infection and do not routinely give antibiotics if the patient is not systemically unwell. Continue emollient and topical corticosteroid; if an antibiotic is justified, topical treatment may suit selected localised non-severe infection and oral treatment may suit widespread or severe infection, while systemic illness requires an oral antibiotic (see BNF).6,14
  • Swab infection that worsens or fails to improve as expected. For recurrent infection, send a skin swab and consider nasal carriage and decolonisation; reassess for eczema herpeticum or a more serious infection.6
  • Do not start unsupervised exclusion diets. Moderate or severe childhood eczema with suspected food allergy needs specialist input, and prolonged milk exclusion requires dietetic supervision.1

Refer and use current systemic pathways

  • In children, refer within 2 weeks when severe eczema has not responded to optimal topical treatment after 1 week or infected eczema treatment has failed. Refer routinely for diagnostic uncertainty, poor control, refractory face, suspected contact allergy, major life impact, growth concern or recurrent serious infection.1
  • Adult and adolescent severe or refractory disease needs dermatology because there is no comprehensive current NICE guideline for this group. Specialist options include phototherapy, conventional systemic immunosuppression, biologics and JAK inhibitors.8,2,7
  • Current NICE options after at least 1 systemic immunosuppressant has failed or is unsuitable are dupilumab and baricitinib in adults; abrocitinib and upadacitinib from age 12; tralokinumab in adults; lebrikizumab from age 12 and at least 40 kg; and nemolizumab from age 12 and at least 30 kg when the relevant biologic positioning rule is met.9,10,3,11,12
  • Stop these advanced treatments at 16 weeks unless at least EASI 50 plus a DLQI improvement of at least 4 points is achieved; baricitinib response is assessed from 8 weeks. Adjust scores for skin colour and disability or communication difficulty.9,10,3,11,12

Prevent relapse and monitor safely

  • Treat flares early and continue topical treatment for about 48 hours after symptoms settle. For a child with 2 to 3 flares per month, consider treatment at recurrent sites on 2 consecutive days each week and review in 3 to 6 months (see BNF).1,14
  • Review technique, adherence, acceptability, sleep and psychosocial impact at each contact, provide a written plan and review repeat emollients at least annually.1,15
  • Before a JAK inhibitor, assess infection, cardiovascular, malignancy and thromboembolism risks, vaccinations and agent-specific blood monitoring. Avoid live vaccines during treatment and use current BNF and SmPC schedules (see BNF).13,27,28,29,14
  • Promptly review new or worsening ocular symptoms on dupilumab, tralokinumab or lebrikizumab; eye pain, visual change or suspected keratitis needs urgent eye assessment. Pregnancy, breastfeeding and vaccination decisions remain drug-specific (see BNF).22,23,24,25,14

Exam traps

  • The CG57 itchy-skin-plus-3 criteria are for children under 12, not a universal adult diagnostic rule.
  • Do not count onset before age 2 as a diagnostic criterion in a child under 4.
  • Erythema can be subtle in darker skin, but persistent pigment change alone does not prove active severe inflammation.
  • For children under 12, do not offer emollient bath additives; for everyone, remember that paraffin-free emollients also create a fabric fire hazard.
  • Correct topical corticosteroid use is safer than leaving active eczema undertreated; rare withdrawal reactions should not be used to promote steroid fear.
  • Tacrolimus and pimecrolimus are not first-line or mild-disease treatments; pimecrolimus under TA82 is the child 2-to-16 face-and-neck option (see BNF).
  • Do not routinely swab a suspected infected flare at first presentation, and weeping or crusting alone does not mandate antibiotics.
  • Continue emollient and topical corticosteroid when treating bacterial infection; stopping anti-inflammatory care can prolong the flare.
  • Suspected eczema herpeticum is treated immediately with systemic aciclovir and same-day referral, not after viral confirmation or antibiotic failure (see BNF).
  • Whole-body wet wraps are not first-line and should not be started without a trained clinician.
  • A positive allergy test may show sensitisation rather than clinical food allergy; avoid unsupervised exclusion diets.
  • Advanced biologic and JAK eligibility is age-, weight- and pathway-specific, and adult-only NICE appraisals are not direct paediatric recommendations.
  • JAK inhibitors need infection, cardiovascular, malignancy, thromboembolism, vaccination and laboratory assessment; pregnancy and live-vaccine rules are drug-specific (see BNF).

Illustrations

Flexural atopic eczemaClinical photograph of erythematous, excoriated, lichenified skin in the antecubital fossae typical of childhood or adult atopic eczema.James Heilman, MD, Wikimedia Commons · CC-BY-SA-3.0
Eczema herpeticumClinical photograph showing grouped monomorphic vesicles and shallow erosions on eczematous facial skin, a red-flag presentation of eczema herpeticum.Mohammad2018, Wikimedia Commons · CC-BY-SA-4.0

Key sources

  1. NICE, Atopic eczema in under 12s: diagnosis and management, recommendations (CG57)Published 12 Dec 2007 | Updated 22 Sept 2025
  2. British Association of Dermatologists, Atopic eczema patient information leaflet (Updated August 2025)
  3. NICE, Abrocitinib, tralokinumab or upadacitinib for treating moderate to severe atopic dermatitis (TA814)Published 3 Aug 2022
  4. NICE, Frequency of application of topical corticosteroids for atopic eczema (TA81)Published 25 Aug 2004
  5. NICE, Tacrolimus and pimecrolimus for atopic eczema (TA82)Published 25 Aug 2004
  6. NICE, Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing (NG190)Published 2 Mar 2021
  7. NHS England, Service specification: specialised dermatology services, adult and children (Specialised service specification)Published 15 Aug 2024 | Updated 1 Apr 2026
  8. British Association of Dermatologists response to NICE on nemolizumab and the adult atopic dermatitis pathway (ID6221 professional organisation submission)Published 16 Sept 2024
  9. NICE, Dupilumab for treating moderate to severe atopic dermatitis (TA534)Published 1 Aug 2018
  10. NICE, Baricitinib for treating moderate to severe atopic dermatitis (TA681)Published 3 Mar 2021
  11. NICE, Lebrikizumab for treating moderate to severe atopic dermatitis in people 12 years and over (TA986)Published 10 Jul 2024
  12. NICE, Nemolizumab for treating moderate to severe atopic dermatitis in people 12 years and over (TA1077)Published 2 Jul 2025
  13. MHRA, JAK inhibitors: measures to reduce cardiovascular, malignancy, thromboembolism, infection and mortality risks (Drug Safety Update)Published 26 Apr 2023
  14. BNF, Eczema treatment summary (BNF online)
  15. NICE, Atopic eczema in under 12s: update information (CG57 update information)Published 12 Dec 2007 | Updated 22 Sept 2025
  16. MHRA, Emollients: severe and fatal burns with paraffin-containing and paraffin-free products (Drug Safety Update)Published 18 Dec 2018 | Updated 26 Aug 2020
  17. MHRA, Topical steroids: new labelling and reminder about severe adverse effects including withdrawal reactions (Drug Safety Update)Published 29 May 2024
  18. BNF, Tacrolimus (BNF online)
  19. BNF, Pimecrolimus (BNF online)
  20. BNF, Aciclovir (BNF online)
  21. NHS England, Commissioning medicines for children in specialised services (Specialised commissioning policy)Published 31 Mar 2017 | Updated 23 Mar 2024
  22. MHRA, Dupilumab: ocular adverse reactions and need for prompt management (Drug Safety Update)Published 29 Nov 2022
  23. Electronic Medicines Compendium, Dupixent summary of product characteristics (Dupilumab SmPC)Updated 23 Oct 2025
  24. Electronic Medicines Compendium, Adtralza summary of product characteristics (Tralokinumab SmPC)Updated 2 Jul 2026
  25. Electronic Medicines Compendium, Ebglyss summary of product characteristics (Lebrikizumab SmPC)Updated 28 Jan 2026
  26. Electronic Medicines Compendium, Nemluvio summary of product characteristics (Nemolizumab SmPC)Updated 8 May 2026
  27. Electronic Medicines Compendium, Cibinqo summary of product characteristics (Abrocitinib SmPC)Updated 4 Jun 2025
  28. Electronic Medicines Compendium, Baricitinib Lilly summary of product characteristics (Baricitinib SmPC)Updated 3 Jun 2026
  29. Electronic Medicines Compendium, Rinvoq summary of product characteristics (Upadacitinib SmPC)Updated 22 Jun 2026
  30. UK Teratology Information Service, Use of topical corticosteroids in pregnancy (Version 2, April 2023)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.