Management of atopic eczema in primary care

A national clinical guideline

March 2011

125

Scottish Intercollegiate Guidelines Network

Part of NHS Quality Improvement Scotland

SIGN

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KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS

LEVELS OF EVIDENCE

1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias

1+ Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias

1 - Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++ High quality systematic reviews of case control or cohort studies

High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2 - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3 Non-analytic studies, eg case reports, case series

4 Expert opinion

GRADES OF RECOMMENDATION

Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.

A

At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results

BA body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

CA body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

DEvidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

GOOD PRACTICE POINTS

Recommended best practice based on the clinical experience of the guideline development group

NHS Evidence has accredited the process used by Scottish Intercollegiate Guidelines Network to produce guidelines. Accreditation is valid for three years from 2009 and is applicable to guidance produced using the processes described in SIGN 50: a guideline developers handbook, 2008 edition (www.sign.ac.uk/guidelines/fulltext/50/index.html). More information on accreditation can be viewed at www.evidence.nhs.uk

NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity and assesses all its publications for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual orientation.

SIGN guidelines are produced using a standard methodology that has been equality impact assessed to ensure that these equality aims are addressed in every guideline. This methodology is set out in the current version of SIGN 50, our guideline manual, which can be found at www.sign.ac.uk/guidelines/fulltext/50/index.html. The EQIA assessment of the manual can be seen at www.sign.ac.uk/pdf/sign50eqia.pdf. The full report in paper form and/or alternative format is available on request from the NHS QIS Equality and Diversity Officer.

Every care is taken to ensure that this publication is correct in every detail at the time of publication. However, in the event of errors or omissions corrections will be published in the web version of this document, which is the definitive version at all times. This version can be found on our web site www.sign.ac.uk.

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Scottish Intercollegiate Guidelines Network

Management of atopic eczema in primary care A national clinical guideline

March 2011

ManageMent of atopic eczeMa in priMary care

ISBN 978 1 905813 72 8

Published March 2011

citation textScottish Intercollegiate Guidelines Network (SIGN). Management of atopic eczema in primary care.

Edinburgh: SIGN; 2011. (SIGN publication no. 125). [March 2011]. Available from URL: http://www.sign.ac.uk

SIGN consents to the photocopying of this guideline for the purpose of implementation in NHSScotland

Scottish intercollegiate guidelines network elliott House, 8 -10 Hillside crescent

edinburgh eH7 5ea

www.sign.ac.uk

contentS

contents

1 introduction ................................................................................................................ 1

1.1 The need for a guideline .............................................................................................. 1

1.2 Remit of the guideline .................................................................................................. 1

1.3 Definitions ................................................................................................................... 2

1.4 Statement of intent ....................................................................................................... 2

2 Key recommendations ................................................................................................. 4

2.1 Referral ........................................................................................................................ 4

2.2 Emollient therapy ......................................................................................................... 4

2.3 Topical corticosteroid therapy ...................................................................................... 4

2.4 Topical calcineurin inhibitors ....................................................................................... 4

2.5 Oral antibiotics ............................................................................................................ 4

3 Diagnosis, referral and patient education .................................................................... 5

3.1 Diagnosis ..................................................................................................................... 5

3.2 Severity assessment and quality of life .......................................................................... 5

3.3 Dermatological comorbidities and associated disorders ................................................ 6

3.4 Referral ........................................................................................................................ 6

3.5 Educational interventions ............................................................................................. 6

4 emollient therapy ........................................................................................................ 7

4.1 Effectiveness ................................................................................................................. 7

4.2 Application technique .................................................................................................. 8

5 topical corticosteroid therapy..................................................................................... 9

5.1 Potency ........................................................................................................................ 9

5.2 Effectiveness ................................................................................................................. 9

5.3 Adverse effects ............................................................................................................. 10

5.4 Application technique .................................................................................................. 11

6 topical calcineurin inhibitors ...................................................................................... 12

6.1 Status and indications for use ....................................................................................... 12

6.2 Comparative effectiveness with topical corticosteroids ................................................ 12

6.3 Reduction in use of topical corticosteroids ................................................................... 12

6.4 Adverse effects ............................................................................................................. 13

6.5 Maintenance therapy .................................................................................................... 13

6.6 Recommendations ....................................................................................................... 13

7 Dressings and wet wrap treatment .............................................................................. 14

7.1 Dressings ..................................................................................................................... 14

7.2 Wet wrap treatment ..................................................................................................... 14

8 antimicrobial measures ............................................................................................... 15

8.1 Introduction ................................................................................................................. 15

8.2 Effectiveness of antimicrobial measures ........................................................................