Atopic dermatitis: the AU general practice approach to eczema

Atopic dermatitis — eczema — is one of the most common chronic conditions seen in Australian general practice. It affects roughly 25% of Australian children and persists into adulthood in a significant proportion, making it a condition most GPs manage throughout a patient’s life rather than referring once and moving on. ASCIA’s eczema resources frame it clearly: this is both a barrier problem and an immune problem, and both need to be addressed simultaneously.

The underlying biology involves impaired skin barrier — in about 30% linked to loss-of-function variants in the filaggrin gene — combined with polarised Type 2 immune activity driven by interleukins IL-4, IL-13, IL-31, and TSLP. Staphylococcus aureus colonises around 90% of affected skin, amplifying inflammation through superantigens and biofilm. The itch–scratch cycle further disrupts barrier, setting up a self-perpetuating pattern.

A. Core clinical — the AU general practice framework

Taking the history

A structured history from ASCIA and the Australasian College of Dermatologists covers:

• Onset and distribution — infant eczema typically involves the face, scalp, and extensor surfaces; older children and adults shift to the flexures (antecubital, popliteal, wrists, ankles, eyelids, neck)
• Severity and impact — itch intensity, sleep disruption, school or work performance, mood, quality of life
• Triggers — soaps, fragrances, wool, heat, sweating, dust mite, pets, specific foods, occupational contactants
• Atopic history — personal and family history of asthma, allergic rhinitis, or food allergy
• Treatment history — which topical steroids, at what potency, for how long, and critically whether the patient stopped early due to steroid anxiety
• Current skincare — emollient type, volume used, bathing frequency and products

Screening for anxiety and depression is important: both are substantially more prevalent in people with moderate-to-severe eczema, and untreated mood disorders worsen itch perception and adherence.

Examination

Morphology varies with disease phase: acute lesions are erythematous, weeping, and vesicular; subacute lesions are excoriated and scaly; chronic disease shows lichenification and hyperpigmentation. Secondary infection presents as golden crusting (impetigo), folliculitis, or — critically — clusters of punched-out vesicles indicating eczema herpeticum.

Atopic stigmata supporting the diagnosis include Dennie–Morgan infraorbital folds, pityriasis alba, palmar hyperlinearity, and keratosis pilaris. Document severity with the Patient-Oriented Eczema Measure (POEM) for consistent tracking in general practice.

The stepwise management framework

eTG Dermatology and ASCIA converge on a clear stepwise model:

Step 1 — foundational daily care

• Emollient ≥250 g per week (adults); ≥100 g per week (children); fragrance-free; applied within three minutes of bathing
• Short, lukewarm, soap-free baths or showers (five to ten minutes); pat dry, emollient immediately
• Trigger avoidance; ASCIA eczema action plan for the patient to take home

Step 2 — flare management Apply a topical corticosteroid once daily until the skin clears (usually one to two weeks), selecting potency by site:

• Face, infants, flexures: mild — hydrocortisone 1%
• Body and limbs: moderate to potent — methylprednisolone aceponate 0.1% (Advantan), betamethasone valerate, mometasone 0.1% (Elocon)
• Palms, soles, lichenified plaques (short course only): very potent — betamethasone dipropionate optimised (Diprosone OV), clobetasol 0.05% (Dermovate)

Fingertip unit dosing guides quantity: one fingertip unit covers two adult hand-areas.

Step 3 — proactive maintenance After a flare settles, continuing the topical corticosteroid (or a topical calcineurin inhibitor) twice weekly to historically affected areas prevents recurrence. Wollenberg et al. (JEADV 2018) demonstrated this approach reduces flare frequency by around 40%.

Step 4 — adjunctive measures

• Topical calcineurin inhibitors (TCI) — pimecrolimus 1% (Elidel) for mild-to-moderate disease on face and flexures; tacrolimus 0.03–0.1% (Protopic) for moderate-to-severe. Steroid-sparing at sensitive sites. The historical lymphoma concern from the boxed warning has not been borne out in clinical cohort data.
• Bleach baths — one-quarter cup household bleach per full bathtub, ten minutes, twice weekly; reduces S. aureus colonisation
• Antibiotics — oral cephalexin or flucloxacillin for clinical impetiginisation; swab if recurrent or treatment failure to exclude MRSA
• Sedating antihistamine — short-term for sleep during a severe flare; non-sedating antihistamines have limited itch benefit in eczema specifically

B. Evidence appraisal — emollients, steroids, and the biologic era

The emollient evidence base

Van Zuuren et al. (Cochrane 2017) found consistent emollient use provided modest reductions in flare frequency and itch. The key practical finding: volume matters far more than specific product — most emollient failure in general practice is inadequate quantity rather than wrong choice. Patients applying 50 g per week when 250 g is needed will not achieve the barrier restoration the data is built on.

Steroid phobia is the second major driver of inadequate eczema control. Patients and parents who under-use topical corticosteroids, particularly due to concerns about “steroid addiction” or atrophy, often accumulate far more cumulative steroid exposure from chronic poorly controlled disease than they would from appropriately used, site-matched treatment. This narrative from online sources is not supported by ASCIA or the Australasian College of Dermatologists.

Proactive maintenance

The counterintuitive finding from multiple proactive therapy trials is that applying topical corticosteroid or TCI twice weekly to historically affected areas — even when skin appears clear — significantly outperforms reactive-only treatment. Microstructural skin inflammation persists under clinically clear skin. Wollenberg et al. established this across multiple study populations, and it is now standard in both ASCIA and eTG guidance.

Biologics and JAK inhibitors in Australia

The targeted therapy landscape for severe atopic dermatitis transformed dramatically between 2022 and 2025. Rubel et al. (Australasian Journal of Dermatology 2025) review the current landscape:

• Dupilumab (Dupixent) — anti-IL-4 receptor α, blocking both IL-4 and IL-13; PBS Authority Required for severe atopic dermatitis aged 6 years and over; fortnightly subcutaneous injection; conjunctivitis in ~10%; no boxed warning for malignancy or cardiovascular events
• Tralokinumab (Adtralza) — anti-IL-13; PBS Authority Required for severe adult disease; similar clinical efficacy
• Upadacitinib (Rinvoq) and abrocitinib (Cibinqo) — oral selective JAK1 inhibitors; faster onset than biologics; PBS Authority Required for severe adult eczema; boxed warning: VTE, major cardiovascular events, and cancer risk; mandatory pre-treatment screening (hepatitis B/C, HIV, TB/IGRA, varicella and MMR immunity, FBC, LFTs, lipids) and ongoing monitoring

Live vaccines are contraindicated during biologic and JAK inhibitor treatment. Vaccinations should be updated before starting treatment.

C. Infection, the atopic march, and common pitfalls

Eczema herpeticum — the emergency

eTG Dermatology and ASCIA classify eczema herpeticum as a same-day emergency. The presentation — sudden marked worsening, clusters of uniform punched-out vesicles or erosions distinct from typical eczema, fever, malaise, lymphadenopathy — should trigger immediate action. Periorbital or eyelid involvement requires same-day ophthalmology input to prevent herpetic keratitis and corneal scarring. Treatment is oral aciclovir for mild cases, intravenous aciclovir for severe disease or infants under 12 months.

The atopic march

Atopic dermatitis in infancy frequently precedes asthma and allergic rhinitis. The LEAP trial evidence, embedded in ASCIA’s early food introduction guidance, supports early introduction of peanut and egg in infants with eczema to reduce food allergy risk — the opposite of what was previously advised. This is a proactive conversation worth having with parents at early consultations.

Common pitfalls

Inadequate emollient volume. Most patients use far less than needed; 250 g per week sounds like a lot but is ~35 g per day for adults with extensive eczema.

Empirical dietary restriction without confirmed food allergy — rarely helpful, nutritionally risky in children, not supported by ASCIA.

Missing the mental health dimension. Anxiety and depression are common; the Better Access MHCP pathway enables cognitive-behavioural therapy for the itch–scratch cycle and comorbid mood disorders. Use Mental Health Care Plan items 2715/2717 where depression or anxiety is the primary issue.

Failing to recognise cutaneous T-cell lymphoma. In older adults with atypical distribution or poor treatment response, dermatology referral for biopsy excludes mycosis fungoides before assuming refractory eczema.

D. Australian operations

MBS pathways

Standard consultations under MBS items 23, 36, and 44 cover most eczema reviews. Moderate-to-severe atopic dermatitis with comorbidities — asthma, allergic rhinitis, depression, anxiety, sleep deprivation — qualifies for a GP Chronic Condition Management Plan (GPCCMP) under items 965 and 967, enabling five allied-health visits per year (ten for ATSI patients). Psychology via Better Access is the most commonly used referral for eczema patients — for itch–scratch behavioural work and comorbid mood.

Skin swab for S. aureus and MRSA is rebatable under item 69300 when recurrent infection is the concern. Pre-biologic and pre-JAK screening bloods (FBC, LFTs, lipids, hepatitis B/C, HIV, IGRA) are rebatable under standard pathology items.

PBS

Topical corticosteroids are on general schedule. Pimecrolimus (Elidel) and tacrolimus (Protopic) require PBS Authority. Dupilumab, tralokinumab, upadacitinib, and abrocitinib all require specialist initiation and PBS Authority Required criteria to be met. Oral antibiotics for clinical infection (cephalexin, flucloxacillin) are on general schedule.

E. Special populations

Infants and young children. Emollient volume and correct TCS potency for site are the two most common failures in paediatric eczema. Wet wraps — emollient and diluted topical corticosteroid under wet bandaging applied overnight — are effective for severe paediatric flares and are better guided by a paediatrician or dermatologist experienced with the technique. Allergy testing should be considered only with a clear clinical suspicion (consistent reaction on repeated exposure), not as a routine workup.

Pregnancy and lactation. Emollients, mild-to-moderate topical corticosteroids, and narrowband UVB phototherapy are safe. Systemic immunosuppressants should be avoided: methotrexate is teratogenic, ciclosporin carries maternal risk. Dupilumab has limited pregnancy safety data; specialist input is appropriate if biologics are needed.

Occupational hand eczema. Healthcare workers, hairdressers, food handlers, and cleaners have disproportionately high rates of hand eczema with a contact component. Referral for patch testing and WorkCover documentation may be appropriate. The overlap with contact dermatitis makes dermatology referral more pressing.

ATSI Australians. Eczema prevalence is elevated in some Indigenous communities, often with greater severity and lower access to adequate emollient volumes. Culturally safe consultation should address cost barriers (250 g per week of quality emollient is not trivial), housing and environmental triggers, and access to specialist services.

When to escalate

Refer urgently to a dermatologist or paediatric dermatologist when:

• Eczema herpeticum is suspected — same-day emergency; contact dermatology or attend ED
• Erythroderma (>90% body surface area) — same-day emergency for fluid and temperature management
• Severe eczema not responding to optimised topical treatment over two to three months
• Biologic or JAK inhibitor candidacy — specialist initiation required for PBS Authority
• Patch testing for suspected contact allergy is needed
• Diagnostic uncertainty, particularly in older adults (exclude cutaneous T-cell lymphoma) or when scabies is possible
• Persistent growth or developmental concerns in children with severe disease

What this article is and is not

This is general health information drawn from current Australian guidelines — ASCIA, eTG Dermatology, the Australasian College of Dermatologists, AMH, and the Eczema Association of Australasia. It does not constitute personal medical advice and does not replace individualised assessment and care from your own GP or dermatologist.

For consumer-friendly Australian resources: Eczema Association of Australasia, HealthDirect — Eczema, Better Health Channel — Eczema, ASCIA patient information.

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Sources cited

1. ASCIA — Eczema action plan
2. Therapeutic Guidelines (eTG) — Dermatology: Eczema
3. Australasian College of Dermatologists
4. Australian Medicines Handbook
5. PBS — dupilumab, tralokinumab, upadacitinib, abrocitinib Authority listings
6. HealthDirect — Eczema
7. Better Health Channel — Eczema
8. Eczema Association of Australasia
9. Rubel et al. — Targeted systemic therapies for atopic dermatitis in Australia (Australasian Journal of Dermatology 2025)
10. Wollenberg et al. — Proactive therapy in atopic dermatitis (JEADV 2018)
11. van Zuuren et al. — Emollients for atopic dermatitis (Cochrane 2017)