How is it assessed?
Assessment of clinical severity
Usually no investigations are performed to diagnose eczema. The condition affects the skin and has a typical appearance. A clinician can diagnose eczema and assess its severity by looking at it. Most children are managed in primary care by the GP. Some children with more severe eczema need specialist advice or treatment and these children will be referred to a dermatologist. Reasons for referral include -:
- Severe eczema not responding to treatment
- Infected eczema that has not responded to treatment
- Diagnosis is uncertain
- Uncontrolled eczema as assessed by child or carer
- Eczema on the face that has not responded to treatment
- An allergic cause for eczema is suspected e.g. contact allergy or food allergy
- Eczema is causing significant social or psychological problems for the child or family
- Repeated or severe infection of eczematous areas
A specialist referral may be required in cases where eczema is controlled with treatment but -:
- Impact on quality of life or psychosocial well-being has not improved (psychological advice)
- Failure to grow as expected
Allergy testing
Where contact or food allergy is suspected tests can be performed. 10% of children with eczema have a food allergy, eating the food makes their eczema significantly worse and removing the food from the diet often results in dramatic improvement of the eczema. The commonest food allergens responsible for this are called the ‘big eight’, they are: peanuts and tree nuts, eggs, cow’s milk, wheat, fish and soya. Children are likely to grow out of most of these allergies except nut and fish allergy which are likely to persist into adult life. Allergy tests may include the following -:
Blood tests -:
- Specific Immunoglobulin E (IgE) allergy to foods e.g. the big eight and any other suspected foods.
- Total IgE – if the serum IgE level is very high, allergy may be present and skin prick testing is usually done as a further test.
Skin tests -:
- Skin prick tests – are carried out and read on one clinic visit – the skin is pricked through a drop of liquid containing the allergen, swelling of the pricked area indicates allergy. Skin prick tests are used to identify food and inhalant allergies.
- Skin patch tests – small amounts of suspected allergen are applied to the skin and protected by a dressing. The dressing is removed after 48 hours and evidence of irritation or inflammation is assessed. Patch testing is used to identify contact allergy to common chemicals and preservatives.
High street and internet allergy testing results do not constitute evidence of allergy.
Assessment of clinical severity
There are clear guidelines on assessment of eczema and categorising it into the mild, moderate or severe category. The guidelines include an assessment of the effect of eczema on quality of life as well as assessment of the skin condition. Severity of the eczema as recorded in the medical evidence will be an important indicator of care required. It will be based on both an assessment of the skin and the effect it is having on the child and their family.
Quality of life assessment -:
- No effect - no impact
- Mild - little impact on everyday activities, sleep and psychosocial well-being
- Moderate - moderate impact on everyday activities and psychosocial well-being and frequently disturbed sleep
- Severe - severe limitation of everyday activities and psychosocial activities, nightly loss of sleep
Assessment of skin -:
- Clear - normal skin
- Mild - areas of dry skin, infrequent itching with or without small areas of redness
- Moderate - areas of dry skin, frequent itching and redness with or without excoriation and localised skin thickening
- Severe - widespread areas of dry skin, incessant itching and redness with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and altered skin pigmentation
