Paediatric atopic eczema: management and the atopic march

Atopic eczema is one of the most common conditions seen in Australian general practice, affecting around 30% of Australian infants in their first year of life — a prevalence among the highest in the world. It is a chronic, relapsing condition of impaired skin-barrier function and immune dysregulation, driven by the Th2 cytokine pathway (IL-4, IL-13, IL-31). Most cases begin before age two, roughly half by six months, and while 50% remit by adolescence, a significant proportion persists into adult life or recurs.

The cornerstone of good outcomes in general practice is not escalation to specialist care — it is the correct use of readily available tools: enough emollient, the right topical corticosteroid on the right body site, a written eczema action plan, and clear communication with families about what to expect. Eczema herpeticum — sudden clusters of monomorphic vesicles with fever — is the one true emergency that must not be missed.

A. Core clinical — the AU general-practice framework

Diagnosis is clinical, based on the UK Working Party criteria: pruritus plus at least three of — flexural or age-characteristic distribution, personal or family atopic history, generalised dry skin, onset before age two, and visible flexural eczema. No investigations are required in typical presentations.

Severity should be scored at every visit using the Patient-Oriented Eczema Measure (POEM) — a seven-item patient-completed tool covering the past week that takes under two minutes. Categories are mild (POEM 0–7), moderate (8–16), and severe (17–28).

History should cover: emollient quantity and frequency; soap products in use; bathing routine; clothing fabrics; known triggers (fragrance, wool, heat, dust mite, pets); sleep disruption; school attendance and psychosocial impact; infection history (frequency of impetigo, any vesicular episodes); and a family atopic history. Ask specifically about recent steroid use and whether the family has steroid phobia — under-treatment due to corticosteroid anxiety is the dominant management failure in the community.

Examination follows the age-typical distribution: cheeks and extensor limbs in infants, flexures (antecubital, popliteal, wrist, ankle, neck) in older children, and face plus hands in adolescents. Document the morphology (erythema, excoriation, lichenification, oozing) and look for signs of infection. Check growth in moderate-to-severe disease.

Investigations are not needed in typical cases. A bacterial skin swab (MBS item 69300) is indicated for recurrent or treatment-failing infection. HSV PCR (item 69380) is urgent if eczema herpeticum is suspected. Specific IgE or skin-prick testing should only be ordered when a specific food trigger is suspected on clinical grounds — not as a broad screening panel — and should be coordinated with ASCIA allergy guidance.

Every patient should leave with a written Eczema Action Plan using the ASCIA template or the RCH Melbourne parent fact sheet. The plan should name the emollient product and quantity, the flare corticosteroid by body site, the maintenance schedule, the bleach-bath protocol if relevant, and the infection red flags.

B. Emollient therapy and the stepwise management ladder — the evidence

Step 1 — Foundational care (all severities): Per ASCIA 2024 and RCH Melbourne CPG:

• Emollient at least twice daily and within three minutes of bathing — target at least 100 g per week in a child, at least 50 g per week in an infant. Fragrance-free paraffin-based ointment is preferred for severe disease; cream for milder presentations. Ointment (QV, Dermeze, Cetaphil Restoraderm) is generally more occlusive and effective than lotion.
• Short (five to ten minute) lukewarm baths daily — not hot; pat (not rub) dry; apply emollient within three minutes.
• Soap-free wash (QV wash, Cetaphil, Hamilton).
• Cotton clothing — avoid wool and synthetic fibres next to the skin; soft seams; short nails plus cotton mittens at night for infants.

Step 2 — Topical corticosteroids for flares: Per eTG Dermatology and AMH Children’s, site-matched potency:

Body site	Potency	Example
Face, eyelids, nappy area, infant body	Mild	Hydrocortisone 1%
Body and limbs, moderate flare	Moderate	Methylprednisolone aceponate 0.1% (Advantan), triamcinolone 0.02%
Body, severe flare or lichenified areas	Potent	Mometasone 0.1% (Elocon)

Apply once daily during the flare until clear (typically seven to fourteen days). Proactive twice-weekly application to prone sites reduces relapses by approximately 40% — this is the most underutilised strategy in community practice.

Step 3 — Topical calcineurin inhibitors (TCIs): Tacrolimus 0.03% (Protopic) PBS Authority Streamlined for ≥2 years; pimecrolimus 1% (Elidel) PBS Authority Streamlined for ≥3 months. Particularly useful on the face, flexures, and for maintenance where steroid-sparing is needed. Initial burning typically resolves within the first week.

Step 4 — Wet wraps and bleach baths: Bleach baths — 1/8 to 1/4 cup of household sodium hypochlorite in a full bath of warm water, five to ten minutes twice weekly — reduce Staphylococcus aureus colonisation and decrease flare frequency. The Huang Paediatrics 2009 RCT showed significant improvement in submerged skin areas. Rinse off after and apply emollient. Wet wraps — emollient plus diluted corticosteroid under wet cotton bandages overnight — are used for severe flares, typically under experienced GP or nurse supervision.

Steps 5–7 — Phototherapy, systemic agents, and biologics are escalation pathways for specialist-managed severe disease. Dupilumab (Dupixent) is PBS Authority Required Section 100 for severe atopic eczema in children ≥6 years after failing topical therapy and at least one systemic agent. The LIBERTY AD PEDS trial (Paller, JAMA Dermatol 2020) demonstrated IGA 0/1 in ~30% vs 3% with placebo; EASI-75 in ~70% vs 27%. JAK inhibitors (upadacitinib, abrocitinib) are PBS Authority Required for severe disease in adolescents ≥12 years and carry a boxed warning for VTE, MACE, and malignancy risk.

A note on prophylactic emollient from birth: Two large RCTs — the BEEP trial (Chalmers/McAleer, Lancet 2020) and PreventADALL (Skjerven, Lancet 2020) — found no reduction in eczema incidence from prophylactic emollient from birth. Earlier positive signals from pilot studies were not confirmed. Current ASCIA guidance does not recommend prophylactic emollient for eczema prevention.

C. The atopic march, food allergy prevention, and infection management

The atopic march — the sequential progression from eczema through IgE-mediated food allergy, asthma, and allergic rhinitis — affects a substantial proportion of children with moderate-to-severe eczema. Cutaneous sensitisation through an inflamed skin barrier (rather than oral tolerance via the gut) is the proposed mechanism, described in the dual-allergen-exposure hypothesis. In the HealthNuts cohort (Murdoch Children’s Research Institute), ~30–40% of infants with eczema developed food allergy, ~30% developed asthma, and 50–70% developed allergic rhinitis by adolescence.

Early allergen introduction (ASCIA 2024 recommendation): Introduce peanut, egg, cow’s-milk dairy, wheat, soy, tree-nut pastes, fish, and sesame from four to six months regardless of family history — all before 12 months of age. Never delay introduction beyond 12 months. For an infant with severe eczema or known egg allergy, consider a skin-prick test before peanut introduction and involve allergy if the test is positive. The LEAP trial (Du Toit, NEJM 2015) demonstrated an 81% relative risk reduction in peanut allergy at age five in high-risk infants randomised to early consumption.

Annual atopic-march surveillance: Review for asthma symptoms (nocturnal cough, exercise-triggered wheeze) and allergic rhinitis at each annual review. Moderate-to-severe eczema with atopic comorbidity qualifies for a Chronic Disease Management plan (MBS items 965/967) with allied-health referrals including psychology under the Better Access Initiative for sleep disturbance and anxiety.

Infection management: Bacterial impetigo (honey-coloured crust) is treated with oral flucloxacillin or cefalexin for seven days per eTG. Mupirocin is reserved for localised disease. Eczema herpeticum — monomorphic vesicles, punched-out erosions, fever, lymphadenopathy — is a paediatric emergency requiring same-day transfer for IV aciclovir per RCH Melbourne CPG. Warn every family about this presentation at diagnosis.

D. Australian operations

MBS items: Standard consultations 23 / 36 / 44 (Levels B/C/D). GPCCMP plan 965 / review 967 for chronic moderate-to-severe eczema with comorbidity (asthma, allergic rhinitis, mental health). Mental Health Care Plan items 2715 / 2717 for sleep deprivation and anxiety in child or carer — very relevant in moderate-to-severe disease. ATSI Annual Health Assessment item 715. Practice-nurse chronic-disease monitoring item 10997 for wet-wrap teaching and action-plan review. Pathology: FBC item 65070; bacterial skin swab item 69300; HSV PCR item 69380 for suspected eczema herpeticum.

PBS items: Hydrocortisone 1%, methylprednisolone aceponate 0.1%, mometasone 0.1%, and betamethasone valerate are on the general schedule. Tacrolimus 0.03% and pimecrolimus 1% are PBS Authority Streamlined. Dupilumab is PBS Authority Required Section 100 for severe eczema ≥6 years (initiated by a dermatologist). Methotrexate, ciclosporin, and azathioprine are PBS Authority Required for severe refractory eczema ≥6 years. Upadacitinib and abrocitinib are PBS Authority Required for severe disease ≥12 years.

GPCCMP template prompts: Moderate-to-severe eczema with asthma, allergic rhinitis, or food allergy; goals — flare prevention, atopic-march surveillance, mental health and sleep support, school liaison. Review every three months recommended; allied-health continuity requires review within 18 months.

Telehealth: Suitable for action-plan review, step-up/down discussion, and photo-documented flare assessment in an established relationship. Not appropriate for a new severe presentation or suspected eczema herpeticum.

E. Special populations

Infants (0–2 years): Emollient is the cornerstone; cheeks and extensor distribution; nappy area usually spared; only 1% hydrocortisone on inflamed infant skin; pimecrolimus from three months. Introduce allergens at four to six months. Cotton mittens at night.

Adolescents: Flexural and facial distribution; lichenification common; psychosocial impact, sleep disruption, and school-absence screening are mandatory. JAK inhibitors and dupilumab accessible for severe disease. Anxiety and depression should be screened with standardised tools.

Severe early-onset eczema in a boy with thrombocytopenia and recurrent infection warrants urgent immunology referral to exclude Wiskott–Aldrich syndrome or other primary immunodeficiency. Document that this consideration was made and acted upon.

ATSI children: HealthNuts did not specifically study ATSI populations, but clinical experience supports high prevalence and potential for underdiagnosis. Use the item 715 ATSI Health Assessment as an entry point; involve Aboriginal Health Workers in skin-care education; access state Aboriginal Community Controlled Health Services for ongoing support.

When to escalate

Refer urgently to the emergency department for: suspected eczema herpeticum (monomorphic vesicles, fever), severe bacterial infection or sepsis, erythroderma, or a very sick infant.

Refer to paediatric dermatology within one to two weeks for: severe flare unresponsive to optimised topical therapy, suspected eczema herpeticum not yet floridly toxic, diagnostic uncertainty, biologic or systemic candidacy, or suspected mimic (Wiskott–Aldrich, hyper-IgE syndrome, Netherton syndrome).

Refer to paediatric allergy or immunology for: suspected food-allergy-driven flares, severe atopic-march workup, pre-introduction risk assessment in a high-risk infant, multifood allergy, or suspected primary immunodeficiency.

Routine referral to a GP-administered skin-barrier nurse or dermatology nurse for wet-wrap teaching, emollient training, and action-plan reinforcement is highly effective and underutilised.

What this article is and is not

This is general health information for patients and families, drawn from current Australian guidelines — ASCIA 2024, Royal Children’s Hospital Melbourne CPG, Therapeutic Guidelines (eTG) Dermatology, and the Australian Medicines Handbook. It does not constitute personal medical advice and does not create a doctor–patient relationship. Management decisions — including all prescribing — are made by your child’s treating clinicians.

For Australian families: ASCIA eczema action plan · Eczema Association of Australasia · HealthDirect — Eczema · Better Health Channel · RCH Kids Health Info — Eczema.

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Sources cited

1. ASCIA — Eczema action plan and infant feeding guidelines 2024
2. Royal Children’s Hospital Melbourne — Clinical Practice Guideline: Eczema 2024
3. Therapeutic Guidelines (eTG) — Dermatology: Eczema
4. Australian Medicines Handbook — Children’s dosing
5. Du Toit G et al. LEAP trial. NEJM 2015;372:803–13
6. Chalmers JR et al. BEEP trial. Lancet 2020;395:962–72
7. Paller AS et al. LIBERTY AD PEDS. JAMA Dermatol 2020

8. Huang JT et al. Bleach baths RCT. Pediatrics 2009;123:e808–14
9. American Academy of Dermatology — Guidelines for atopic dermatitis. JAAD 2024
10. PBS — Dupilumab Authority Required Section 100
11. Eczema Association of Australasia
12. HealthDirect — Eczema in children
13. Better Health Channel — Eczema (atopic dermatitis)