Assessing needs in relation to severity of eczema
The main evidence to assess severity of eczema will be the label given to the eczema in the medical evidence e.g. ‘moderate’ eczema. This will give a good indication of what treatment is being given and this can be confirmed using the medical evidence.
Treatment changes depending on severity of eczema at most recent clinical review. Eczema may become more severe over time, for example moving from mild eczema into the moderate category. Alternatively it may remain mild, moving into the moderate category only during flare ups. When reviewing medical evidence consider what category the child’s eczema is in, the majority of the time. Children in the moderate category may move into the severe category during flare ups. Flare ups may be infrequent – the child will be in the moderate category for care needs most of the time. Flare ups may be present for 2 weeks out of every 4 – the child will have eczema that is labelled ‘moderate’ at the moment but have care needs of a child with severe eczema most of the time. The category used for care needs assessment should be the category the child is in for at least half of the time.
Children aged 5 and under
Mild Eczema
No care needs are anticipated for children with mild eczema. Children with mild eczema will require daily application of emollients and use of steroid creams or other treatments during flare –ups. Bath time emollients or soap substitutes may be used. Emollients won’t need to be applied more than twice a day for the majority of the time and this can be done when the child is being dressed or undressed at the beginning and end of the day.
Moderate and Severe Eczema
Children aged 5 and under with moderate or severe eczema are likely to have care needs. Care is mainly related to providing daily treatment. The mainstay of treatment is the application of emollients to the skin. In a severe case these may need to be applied 4-6 times daily to the whole body. The child will need to be undressed on each occasion, this can done on each occasion the nappy is changed in young children but this adds considerably to the time taken to change a nappy and means significant amounts of emollients or other creams will need to be transported wherever the child goes. It may be difficult to find a childcare provider for such children.
Wet wraps or bandages may need to be used at night, this prolongs bath time and preparation for bed significantly. In the morning removal of bandages can be prolonged and difficult, especially if the eczema is weeping and areas of bandage have become stuck to the eczema overnight. These two treatments make the most significant contribution to the extra time taken to care for a child with eczema.
In addition to these treatments other treatments may be required and these include -:
- Wound care.
- Use of bath time treatments instead of soap and shampoo to promote skin hydration.
- Use of targeted steroid creams to worst affected areas, different potencies of cream may used for different areas of the body.
- Antihistamine drugs at night to aid sleep and reduce itching.
- Systemic treatment with immunomodulating drugs such as ciclosporin or steroids.
- Children who are unable to sleep properly because of itchy skin or who look different to other children may develop behavioural problems requiring extra care or supervision from parents in addition to physical care provided.
- Children with eczema due to food allergy are likely to require extra supervision from parents or carers in the pre-school years particularly to prevent ingestion of the foods. It may be difficult to find a childcare provider for such children.
Children aged 6 and over
Children with severe eczema will have care needs and children with moderate eczema with certain features are also likely to have care needs. In both moderate and severe cases, care is mainly related to providing daily treatment. The mainstay of treatment is the application of emollients to the skin. In a severe case these may need to be applied 4-6 times daily to the whole body. On each occasion, the child will need to be undressed and provision may need to be made to provide treatment during the school day. The child may do this themselves under supervision at school or the parent may come in to school to apply emollients during the day. This is because schools cannot provide a suitable person to apply emollients to children during the school day. Similar arrangements will be made for swimming. Emollients need to be applied both before and after swimming and either the parent will come in to do this or school staff will supervise the child doing this for themselves.
Out of school, it may be difficult to find a childcare provider for such children. Wet wraps or bandages may need to be used at night prolonging bath time and preparation for bed significantly. In the morning, removal of bandages can be prolonged and difficult especially if the eczema is weeping and areas of skin have become stuck to the eczema overnight. These two treatments, application of emollients 4 or more times a day and bandaging make the most significant contribution to the extra time taken to care for a child with eczema.
In addition to these treatments other treatments may be required and these include -:
- Wound care.
- Use of bath time treatments instead of soap and shampoo to promote skin hydration.
- Use of targeted steroid creams to worst affected areas, different potencies of cream may used for different areas of the body.
- Antihistamine drugs at night to aid sleep and reduce itching.
- Systemic treatment with immunomodulating drugs such as ciclosporin or steroids.
- Children who are unable to sleep properly because of itchy skin or who look different to other children may develop behavioural problems requiring extra care or supervision from parents, teachers or carers in addition to physical care provided.
Identifying children with moderate eczema who have care needs
Many children with moderate eczema will not have care needs. A child with moderate eczema with any one of the following features identified from the medical evidence is likely to have care needs related to their eczema management -:
- 1 admission to hospital in the previous year with eczema.
- 2 or more hospital out-patient appointments in the previous 12 months.
- 4 or more GP attendances over previous 12 months with problems related to their eczema.
- a recent prescription (within 6 months) or a repeat prescription for antihistamines at night.
