Atopic Eczema
Red Flags — must not miss; must act
| Red flag | Why dangerous | Action |
|---|---|---|
| Eczema herpeticum — rapidly spreading punched-out erosions; fever; unwell | Herpes simplex superinfection can be life-threatening. Monomorphic punched-out vesicles and erosions spreading rapidly; fever; malaise; periorbital involvement. IV aciclovir required. Cannot be treated at home. Delay → sepsis; meningitis. | 999 or same-day A&E — IV aciclovir |
| Signs of anaphylaxis — associated with food allergy trigger | In children with severe eczema and known food allergy, a trigger food exposure can cause anaphylaxis. If anaphylaxis present: 999; IM adrenaline 0.5mg (1:1000) IM anterolateral thigh; ambulance. Prescribe adrenaline auto-injector (EpiPen; Emerade) for at-risk patients. | 999 — IM adrenaline; ambulance |
| Widespread superinfection with sepsis features | Severe bacterial superinfection (S. aureus; streptococcus) can cause sepsis — particularly in children; immunocompromised. Fever; tachycardia; raised WCC; CRP. Urgent hospital admission; IV antibiotics. | Same-day A&E — IV antibiotics; sepsis review |
| Erythroderma — ›90% body surface area involvement | Erythrodermic eczema: temperature dysregulation; fluid loss; cardiovascular instability; secondary infection. Medical emergency requiring hospital admission and intensive management. | Same-day hospital — urgent dermatology |
| Psychological crisis — active suicidal ideation related to eczema | Severe eczema causes significant psychological distress. PHQ-9 Q9: if suicidal ideation present in the context of severe eczema — urgent mental health review. The DLQI (Dermatology Life Quality Index) in severe eczema can be comparable to severe psoriasis; chronic pain; cancer. | PHQ-9 Q9 ≥1: urgent mental health; same-day if crisis |
Safeguarding — Eczema and Vulnerability
💕 Psychological distress and self-harm
- PHQ-9 Q9: ask specifically about suicidal ideation in patients with severe eczema
- Sleep deprivation from chronic itch is an independent risk factor for depression
- Itch-scratch cycle can have compulsive elements; note if scratching is causing self-harm
- Refer to NHS Talking Therapies or dermatology psychology service if significant psychological impact
🏠 Child eczema and parenting stress
- Eczema in young children causes significant family stress; parental sleep deprivation; relationship difficulties
- If child eczema is severely undertreated: consider whether parent has capacity to manage treatment; referral to health visitor
- If child is presenting repeatedly with poorly controlled eczema: explore family context; barriers to treatment
💼 Occupational vulnerability
- Healthcare workers with hand eczema: unable to work if open wounds; infection risk to patients
- Employer discrimination: Mrs. Mensah may be self-conscious about visible eczema at work
- Occupational health referral: right to reasonable adjustments; glove protocol; alternative soap-free hand cleaners
- Sick note: may be needed if eczema prevents safe working
📋 Medication adherence and safety
- Steroid phobia leading to under-treatment: directly linked to significant harm (uncontrolled eczema; infection; psychological impact)
- Topical TCS misuse (overuse): real risk of skin atrophy; telangiectasia; striae — especially face and flexures
- Ensure patient has written eczema action plan — this reduces unnecessary steroid use (allows step-down) AND prevents under-use
👔 Steroid Phobia
The most clinically important psychosocial factor in this consultation. Inherited from her mother’s experience. Leads to systematic under-application of TCS; treatment failure; and escalating eczema severity. Must be addressed with specific evidence, not dismissal.
"I understand the worry about the steroid cream — it is a very common concern. Let me explain what is safe and what is not safe, so you can use it with confidence."Management change: full steroid counselling with FTU; written action plan; distinction between appropriate use and harmful overuse
👔 Embarrassment and Self-Image
Mrs. Mensah is self-conscious about her appearance at work. Visible eczema on the arms; neck; and hands is difficult to conceal in a care home setting. The embarrassment is not trivial — it affects her professional confidence and social functioning.
"How has the skin been affecting you at work? Are you feeling self-conscious about it? I want to understand the full impact."Management change: address quickly and effectively; consider DLQI; social prescribing for psychological support if needed
😴 Sleep Disruption
Itch worsens at night — sleep deprivation compounds depression; reduces immune regulation; worsens itch sensitivity. Mrs. Mensah’s POEM sleep score likely contributes significantly to her total score of 16.
"Has the itch been waking you at night? Poor sleep from eczema is one of the most underappreciated aspects — it affects your mood, your immunity, and how well your skin heals."Management change: emollient at bedtime; cotton loose clothing; cool bedroom; chlorphenamine 4mg at night during severe flares
💼 Occupational Impact
Healthcare worker with wet work: hand eczema directly affects her ability to work safely. Open skin = infection risk to patients; glove intolerance; painful cracking preventing dexterous care tasks.
"Your work involves a lot of hand washing — that is likely a significant factor in your hand eczema. Let’s make sure you get the right support at work — including a referral to occupational health."Management change: occupational health referral; prescribed barrier cream protocol; alternative to soap (alcohol gel); sick note if unable to work safely
- Not addressing steroid phobia even when it emerges — leaving Mrs. Mensah with the same steroid fear means treatment failure will continue
- Not identifying the occupational trigger — treating eczema without addressing the cause means the treatment will need to be continued indefinitely
- Not administering POEM score — severity is under-documented
999 / Same-Day Hospital
Immediate- Eczema herpeticumPunched-out vesicular erosions; fever; rapidly spreading; 999; IV aciclovir
- Erythroderma (>90% BSA)Temperature dysregulation; cardiovascular instability; same-day hospital
- Sepsis from superinfectionFever; tachycardia; systemically unwell; 999 / A&E
Same-Day to 2 Weeks
Days- Significant bacterial superinfectionWeeping; golden crusts; extending rapidly; oral flucloxacillin; same-day review
- Severe eczema POEM ≥17Unable to function; urgent dermatology; consider short-course prednisolone (not NICE first-line) with specialist input
Primary Care
NICE CKS stepwise- Moderate-severe flare (POEM 16) — Mrs. MensahStep up TCS to potent; emollient 500g/week; FTU; occupational health; 4–6 week review
- Mild-moderate uncomplicated flareEmollient; mild TCS; trigger avoidance; POEM review
- Maintenance phaseRegular emollient; proactive TCS ×2/week on problem areas
- Not screening for eczema herpeticum features — sending a patient with eczema herpeticum home with topical antibiotics is a serious safety error
- Not examining the hands specifically in a healthcare worker with hand eczema — the distribution and characteristics of hand eczema directly guide the occupational health referral and the barrier cream protocol
- Not swabbing a healthcare worker with weeping or crusted hand eczema — MRSA colonisation has infection control implications for the care home; this is a patient safety issue as well as a clinical one
"Your eczema is a skin condition where the outer layer of your skin — the barrier — is not working as effectively as it should. This means moisture escapes too easily and irritants get in too easily. When the skin becomes inflamed, it releases chemicals that cause the itch. And scratching releases more chemicals; causes more inflammation; and the cycle continues. The emollient cream acts as a replacement barrier — it has to be applied regularly, not just when the skin is dry, because the barrier needs to be maintained constantly. The steroid cream tackles the inflammation directly. I want to address your concern about the steroid cream specifically. Skin thinning from steroids is a real risk — but it only happens with prolonged use of potent steroids on the wrong areas. The way we use steroids for eczema is different: short courses; stepping up during flares; stepping down when controlled; and using the mildest effective preparation. Using the cream correctly for a short time is safe. What is not safe is using it too little — because under-treated eczema causes its own harm: it becomes infected; it prevents sleep; it causes scarring from scratching; and it affects your mental health."
"My mother said steroid creams damaged her skin. Is that going to happen to me?"
"Your mother’s experience — and her concern — makes complete sense. Skin thinning from steroids is real, but it happens with: (1) prolonged continuous use over many weeks; (2) on the face or skin folds with a potent steroid; (3) without taking breaks. The way we are going to use the cream is very different: I am going to give you a written plan that tells you exactly which cream to use on which area; for how many days; and when to stop. Using a medium-strength cream on your arm for 2 weeks is not going to thin your skin. Leaving the inflammation untreated for months — which is what has been happening — is more likely to cause skin changes from the eczema itself."
Contact dermatitis (irritant or allergic)
May coexist with atopic eczema. Irritant: wet work; soap; rubber chemicals. Allergic: type IV; patch testing at dermatology. Consider if hands disproportionately affected; pattern fits contact exposure.
Psoriasis
Well-demarcated; silvery scale; extensor surfaces; nail changes; scalp. Distinguish from eczema: psoriasis affects extensors; eczema affects flexures. Koebner phenomenon.
Eczema herpeticum
Excluded today: no fever; no punched-out monomorphic erosions; not systemically unwell. Document as excluded. Safety-net given.
MRSA superinfection
Healthcare worker: nasal swab + skin swab to exclude. Infection control implications in care home setting. Specialist advice if MRSA confirmed.
- Dismissing steroid phobia without addressing it — a patient who leaves with the same steroid fear will continue to under-apply; the same treatment failure will recur
- Failing to refer to occupational health in a healthcare worker with occupational hand eczema — the trigger will continue to drive relapse regardless of how well topical management is optimised
Validate — the concern is completely understandable
Her mother’s experience gave her a genuine and protective instinct. Never dismiss it — acknowledging that the concern is valid makes the subsequent evidence more credible.
"I completely understand the worry — your mother’s experience has made you cautious, and that is a natural protective instinct. I want to explain what is true about steroid creams, and what is a myth, so you can use them with confidence."Explain — when TCS is safe; when it is not
The specific, evidence-based explanation is: skin atrophy is real but requires prolonged high-potency use in the wrong location. A 2-week course of betamethasone 0.1% on the arms is safe. Hydrocortisone 1% on the face is safe for short periods. The FTU demonstrates what “enough” looks like.
"The skin thinning that happened to your mother is a real risk — but it happens with prolonged, daily use of a strong cream on the face or skin folds without any break. What I am prescribing — a medium-strength cream on your arms for 2 weeks, with a written plan for when to stop — is safe. I am also going to show you exactly how much cream to use."Negotiate — written eczema action plan as a contract of safety
The written action plan transforms the steroid phobia into a navigable, bounded protocol. It tells Mrs. Mensah exactly when to step up; when to step down; how much to use; and what signs should make her seek help. It removes uncertainty and replaces it with control.
"I am going to give you a written plan today — it tells you exactly which cream to use on which part of the body; how much to use; for how many days; and when to stop. With a plan like this, you are in control. The risk of using too much is managed by the plan — and the risk of using too little — which is what has been happening — is prevented."The skin barrier defect in atopic eczema results in transepidermal water loss (TEWL) — the skin dries out unless the barrier is maintained with emollient. Emollient must be: (1) used regularly — not just when the skin is dry; (2) used in large quantities (500g/week is the minimum for body eczema — most OTC moisturisers come in 200–400ml tubes and would run out in days); (3) used before TCS (apply emollient first; wait 20–30 minutes; then apply TCS). The emollient is not optional — it is the foundation on which TCS efficacy depends.
Prescribe: Epaderm ointment 500g (body; overnight; very greasy; best barrier); Diprobase gel 500g (daytime; lighter; good for work use); aqueous cream or Oilatum SHOWER EMOLLIENT (as soap substitute — never leave on as leave-on emollient — it causes irritation if not washed off). Paraffin-based emollients: fire risk — warn patient; do not smoke near open flame when using paraffin-based emollient. Apply in direction of hair growth to reduce folliculitis.
Itch worsens at night. The itch-scratch cycle is amplified during sleep: scratching releases inflammatory mediators; worsens eczema; disrupts sleep further. Breaking the cycle requires: (1) physical barriers (cotton mittens; appropriate clothing); (2) cool room temperature; (3) emollient at bedtime; (4) cut fingernails short. Sedating antihistamine (chlorphenamine 4mg) at night may help sleep during acute flares — but note: evidence for antihistamines in eczema itch is limited; they help sleep via sedation rather than direct antipruritic effect.
Cool (16–18°C) bedroom. 100% cotton loose clothing. Emollient applied generously at bedtime. Cut fingernails short. Cotton mittens or bandaging if scratching uncontrolled during sleep. Chlorphenamine 4mg at night during severe flares (not long-term; not in children under 6 months; causes daytime sedation — warn and document).
Trigger avoidance reduces flare frequency and severity. Common triggers: house dust mite (allergen-impermeable mattress and pillow covers; hot washing bedding at 60°C weekly; avoid carpet in bedroom); pet dander (avoid pets in bedroom; HEPA filter); fragrances (use fragrance-free personal care products; avoid fragranced washing powder — non-bio is not necessarily fragrance-free — use Surcare or similar); clothing: 100% cotton next to skin; avoid wool directly on skin; overheating and sweating triggers itch.
Identify her specific triggers. Occupational: alcohol gel instead of soap for some handwashing episodes; non-latex gloves with cotton liners; barrier cream (Diprobase or Neutrogena Norwegian Formula) applied before shift. Home: review washing powder; fragrance-free skin products; HDM reduction if bedroom triggers identified.
Habit reversal training (HRT) is a CBT-derived psychological intervention specifically for the itch-scratch cycle in eczema. It teaches awareness of scratching (which often occurs automatically without conscious awareness); the introduction of competing responses (pinching instead of scratching; applying emollient instead of scratching); and relaxation techniques. RCTs show significant reduction in itch and scratching with HRT. NHS Talking Therapies can provide CBT — specify “itch-scratch cycle; habit reversal training” in the referral.
National Eczema Society: eczema.org — helpline 0800 089 1122; patient support; local groups. NHS Talking Therapies self-referral or GP referral. British Skin Foundation: britishskinfoundation.org.uk. Dermatology psychology service — if available locally.
Hand eczema in a healthcare worker is an occupational health emergency and a patient safety issue. Open or weeping skin on the hands of a care home worker = infection risk to vulnerable residents. Management hierarchy: (1) reduce exposure (alcohol gel instead of soap for some episodes); (2) barrier protection (barrier cream; cotton liner gloves under non-latex gloves); (3) treatment of existing hand eczema (emollient + correct TCS — ointments are more effective for hand eczema; potent TCS appropriate for hand dorsum); (4) occupational health referral; (5) sick note if unable to work safely.
Diprobase gel (daytime; before gloves; light non-greasy); Epaderm ointment (overnight; intensive overnight repair); betamethasone 0.1% ointment (back of hands; NOT between fingers; apply 2×/day for up to 14 days during flare); soft paraffin under cotton gloves overnight. NEVER: potent TCS in web spaces; prolonged potent TCS on palms without monitoring.
A written eczema action plan reduces TCS use (allows appropriate step-down); reduces GP appointments (patient self-manages minor flares); addresses steroid phobia (gives clear rules for safe use); and reduces eczema-related hospitalisations. NICE CKS recommends written action plans as a core component of eczema management. The plan should include: (1) baseline maintenance (emollient; frequency; quantity); (2) mild flare: which TCS; which area; duration; (3) moderate flare: step up to which preparation; (4) when to contact GP; (5) emergency signs (eczema herpeticum).
Maintenance: Epaderm ointment 4×/day body; twice daily face; soap substitute always. Flare: betamethasone 0.1% body and limbs ×2/day for maximum 14 days; hydrocortisone 1% face ×2/day for maximum 7 days; step back to emollient alone when clear. Contact GP: if flare not improving in 2 weeks; if signs of infection; if punched-out blisters or fever (A&E immediately).
- Hydrocortisone 1% cream or ointment ×2/day for maximum 7 days
- Never potent TCS on face: skin atrophy; telangiectasia; perioral dermatitis; glaucoma (periorbital)
- Eyelids: hydrocortisone 0.5% (lower potency); ophthalmology referral if recurrent periorbital TCS use needed
- If hydrocortisone 1% inadequate on face: tacrolimus 0.1% ointment (Protopic) or pimecrolimus 1% cream (Elidel) — TCI preferred over potent TCS on face
- Betamethasone valerate 0.1% (Betnovate) ×2/day — up to 14 days for flare
- OR mometasone furoate 0.1% (Elocon) ×once daily — equivalent potency; once-daily dosing improves adherence
- OR fluticasone propionate 0.05% (Cutivate) ×twice daily
- Hands: ointment formulation preferred (more occlusive; better penetration)
- FTU: arms = 3 FTU each; demonstrate at consultation
- Bacterial (S. aureus): Fucidin (fusidic acid 2%) cream or ointment ×3/day for 7 days
- Or combination: Fucibet (betamethasone + fusidic acid) if needs TCS and antibiotic simultaneously — 7 days only (resistance concern)
- Widespread: oral flucloxacillin 500mg QDS ×7 days; penicillin allergy: cefalexin 500mg TDS
- MRSA: specialist dermatology advice; rifampicin + fusidic acid
- Viral (eczema herpeticum): 999 — IV aciclovir — do NOT treat with topical steroid
- Tacrolimus 0.1% ointment (Protopic): adults; moderate-severe eczema; face; flexures; eyelid skin (steroid-sparing); ×2/day; initial burning/stinging (settles after 1 week)
- Pimecrolimus 1% cream (Elidel): adults and children ≥2y; mild-moderate; better tolerated (less stinging)
- Both: no skin atrophy risk — preferred over potent TCS for face; eyelids; genitalia; skin folds
- Proactive use ×2/week on problem areas: reduces relapses
- Phototherapy (narrowband UVB): first-line secondary care; 3×/week ×6–8 weeks; effective; no immunosuppression
- Ciclosporin: NICE CKS first-line systemic; 2.5–5mg/kg/day; monitor BP; renal function; FBC monthly; maximum 1–2 years continuous use
- Dupilumab (Dupixent): NICE TA534; adults; EASI ≥16; failed ciclosporin; subcutaneous 300mg fortnightly; highly effective
- JAK inhibitors (abrocitinib; upadacitinib): NICE TA878/TA879; oral; specialist only
Select site and severity — eczema TCS selection guide
"This cream needs to go on at least 4 times a day — when you wake up; before lunch; before dinner; and before bed. I know that seems like a lot. The reason is that your skin cannot keep its own moisture in because of the eczema, so we are replacing the barrier from the outside. You also need to use it instead of soap — every time you wash. The prescription I am giving you is for 500g — that should last about a week for your body. And if you have paraffin-based creams at home, please do not smoke near open flames when you are wearing them — they can make clothing flammable."
Emollient prescribing: NICE CKS cornerstone; 500g/week body; soap substitute always; apply before TCS; in direction of hair growth; paraffin fire risk must be documented and counselled. Most common SCA error: not quantifying emollient — saying “use moisturiser” without prescription quantity and technique education misses the Tasks mark.
"This is a mild steroid cream for your face. Use it twice a day for a maximum of 7 days when your face flares. Stop it when the skin is clear and go back to just the moisturiser. If it is not working after 7 days on your face, come back and we will try a different type of cream — one that doesn’t have steroid in it at all."
Hydrocortisone 1%: mild TCS; face; flexures; children; maximum 7 days face. FTU guide is a core prescribing competency for eczema — demonstrating it in the SCA is a Tasks mark. Never potent TCS on face — this is the most common TCS prescribing error.
"I am prescribing you a medium-strength cream for your arms and body. This is safe on these areas for up to 2 weeks. I am going to show you exactly how much to use — [demonstrate FTU] — one of these squeezes covers both your hands; you need 3 of these for one arm. Do not use it on your face — only the other cream I am giving you on your face. When the skin on your arms is back to normal, stop the stronger cream and just use the moisturiser again."
Betamethasone 0.1% / mometasone 0.1%: potent TCS; body and limbs only; Mrs. Mensah’s step-up prescription. Demonstrate FTU at consultation — Tasks mark. NEVER face; eyelids; genitalia; skin folds — most common TCS prescribing error. 14-day maximum per course; step down to emollient when clear. Proactive ×2/week use when in remission reduces relapse risk.
"This cream works on the inflammation in your skin without the steroid. It is particularly useful on the face because it doesn’t cause skin thinning. When you first apply it, it may sting or burn a little — that usually settles after a few days. If you use it twice a week once your face is clear, it can help prevent the eczema from coming back in that area."
TCI (tacrolimus 0.1%; pimecrolimus 1%): steroid-sparing; no atrophy; preferred for face; eyelids; flexures; steroid phobia; TCS atrophy. Initial burning/stinging — warn. NICE CKS: second-line after TCS for face/neck. Proactive ×2/week maintenance reduces relapse. Black-box malignancy warning largely withdrawn — reassure if patient asks. For Mrs. Mensah with steroid phobia: TCI is an excellent face option that addresses the phobia by avoiding steroids on that site entirely.
"There are signs of a bacterial infection in your eczema — the yellow crusting is the typical sign. I am treating that first with an antibiotic cream before stepping up the steroid cream — because putting a stronger steroid on infected skin would suppress your immune response and make the infection worse. Once the infection is clear in about a week, we step up the steroid cream."
Fusidic acid: bacterial superinfection (S. aureus) only; 7 days maximum topical (resistance). TREAT INFECTION FIRST then step up TCS. Fucibet: combination; 7 days only. MRSA: specialist + infection control in care home. SCA: stepping up TCS into infected eczema without treating infection first = Tasks deduction. Eczema herpeticum: IV aciclovir — not antibiotics.
"This injection works on the specific pathway that drives your eczema inflammation. It is not a steroid and it doesn’t suppress your immune system in the way that older tablets do — so the infection risk is very low. You inject it yourself at home fortnightly. The most common side effect is some redness and swelling at the injection site — and some people develop eye irritation. I want you to let me know if your eyes become red or sore so we can sort that out."
Ciclosporin: NICE CKS first-line systemic; monitoring: BP; U&E; creatinine; LFTs; FBC (fortnightly ×3m then monthly); maximum 1–2 years; nephrotoxicity; hypertension. Dupilumab (Dupixent; NICE TA534): IL-4/IL-13 inhibitor; moderate-severe; failed ciclosporin; EASI ≥16; subcutaneous fortnightly; conjunctivitis (monitor); no immunosuppression. GP role: monitoring; shared care. JAK inhibitors: NICE TA878/TA879; TB screen first; thromboembolism risk.
Work and Occupational Safety
Mrs. Mensah’s hand eczema affects her ability to work safely as a healthcare assistant. Open wounds increase infection risk to residents. Occupational health referral is mandatory. She has legal rights to reasonable adjustments under the Equality Act 2010 (disability includes chronic skin conditions affecting daily activities).
"Your eczema on your hands affects your ability to work safely, and you have a right to reasonable adjustments from your employer — that might be a different type of hand cleaner; different gloves; or adjusted duties while the eczema is treated. Occupational health will advise on this."Self-Consciousness and Stigma
Visible eczema on arms; neck; and hands in a care environment creates self-consciousness and perceived stigma. Mrs. Mensah is embarrassed. This affects professional confidence and social functioning. Addressing it is part of the eczema management — not separately, but as a motivation for effective treatment: getting the eczema controlled will directly improve her confidence at work.
"I know how visible this is — and I understand it affects how you feel at work. Getting this under control quickly is our goal, and with the right treatment applied correctly, most people see significant improvement within 4 weeks."Sleep and Fatigue
Chronic itch disrupts sleep; sleep deprivation worsens itch sensitivity; worsens immune regulation; worsens eczema. This vicious cycle must be broken. Emollient at bedtime; cool bedroom; cotton clothing; chlorphenamine 4mg during acute flares — each contributes. Effective treatment of the eczema itself is the most powerful sleep intervention.
"The itch at night is one of the most exhausting aspects of eczema. As the eczema improves with the right treatment, the night-time itch should reduce significantly. In the meantime, a cool bedroom; cotton clothing; and putting the emollient on before bed all help."Relationships and Intimacy
Eczema affects skin-to-skin contact; relationships; and intimacy. The self-consciousness of visible eczema reduces confidence in social and intimate situations. Opening this topic sensitively — “has the eczema been affecting your relationships or your social life at all?” — allows patients to raise concerns they would not spontaneously share.
"Sometimes eczema affects things like relationships and social confidence as well. Has that been an issue for you? It is absolutely something we can discuss."Mental Health — PHQ-9 7
PHQ-9 7 (mild depression) in context of eczema, sleep disruption, and occupational embarrassment. Mild depression may resolve as eczema improves — watchful waiting with NHS Talking Therapies referral. Habit reversal training (CBT for itch-scratch cycle) also addresses anxiety and low mood. If PHQ-9 ≥10 at review: formal depression management. Monitor Q9 at each visit.
"I noticed your mood score is a little low, which is not surprising given how much this has been affecting your sleep and your work. I am going to refer you to our talking therapy service — they can help with the itch-scratch cycle as well as the mood, and I think as the eczema improves your mood should improve with it."Identity and the Atopic March
Mrs. Mensah has had eczema since childhood — it is part of her identity in a complex way. She may have learned to hide it; to not discuss it; to manage alone. The consultation is an opportunity to reframe: eczema is a medical condition with effective treatments; it is not something she should simply endure. The written eczema action plan empowers self-management and reduces helplessness.
"You have been managing this for a long time. I want to give you a plan today that puts you in control — so that when the next flare comes, you know exactly what to do and you do not have to wait for a GP appointment to start treating it."Today — Prescriptions; FTU demonstrated; written action plan; referrals; safety-net
Betamethasone 0.1% ointment (arms; neck; hands — back of hands ×2/day ×14 days); hydrocortisone 1% cream (face only ×2/day ×7 days); Epaderm ointment 500g (body emollient; 4×/day); Diprobase gel 500g (daytime/work emollient; soap substitute). Skin swab (hands; nasal swab for MRSA). FTU demonstrated at consultation. Steroid phobia addressed. Written eczema action plan provided. Occupational health referral made. NHS Talking Therapies referral. POEM 16 documented. 4–6 week review booked. Eczema herpeticum safety-net given.
1 Week — Swab results; antibiotic course review (if infection present)
If swab showed infection: is antibiotic course complete? Review hand infection status. If MRSA: specialist notification; infection control for care home. If no infection: confirm appropriate TCS use in first week; any concerns? Phone or face-to-face as appropriate.
4–6 Weeks — Main review: POEM re-score; TCS step-down; occupational health update
Face-to-face. POEM re-score: target <8 or ≥3-point reduction. TCS review: has betamethasone 0.1% been used correctly? Is it working? Step down to proactive ×2/week if in remission. Face: is hydrocortisone 1% adequate or switch to TCI? PHQ-9. Occupational health update: has appointment been made? Swab results actioned? If POEM not improved: consider patch testing referral; dermatology if POEM ≥17.
6–12 Weeks — Maintenance; proactive regimen; dermatology if not improving
If POEM improved and in remission: proactive TCS ×2/week on prone areas + daily emollient. If POEM unchanged despite optimal topical management: dermatology referral (patch testing; phototherapy; ciclosporin consideration). PHQ-9: if not improving as eczema improves: formal depression treatment. NHS Talking Therapies progress.
Annually — POEM; atopic comorbidities; emollient quantity; TCS review
Annual POEM. Review atopic march: asthma; allergic rhinitis — comorbidities worsen eczema. Emollient quantity check (prescription request frequency). TCS review: any signs of atrophy? Proactive regimen adherence. Psychological wellbeing. Occupational situation.
PETS monitoring mnemonic for eczema
POEM score: at every review — did it improve by ≥3 points? Emollient: is she getting enough (500g/week on prescription)? TCS: using correctly? Right potency for right site? No atrophy signs? Superinfection: any signs of bacterial or viral infection at each visit?
⚠ Three critical safety-nets for Mrs. Mensah
Documentation requirements
- Not demonstrating the FTU — under-application is the most common cause of TCS failure; demonstrating FTU is a core Tasks mark
- Not addressing steroid phobia specifically — a patient who leaves with the same fear will continue to under-apply
- Not identifying the occupational trigger (wet work; care home) — the trigger will perpetuate relapse regardless of optimal topical management
- Prescribing potent TCS for the face — never potent TCS on face; most common TCS prescribing error
- Stepping up TCS potency into infected skin without treating infection first
- Not prescribing adequate emollient quantity (prescribing “a small tube of moisturiser” is not adequate treatment)
- POEM 16 documented at baseline
- Emollient 500g/week prescribed; quantity and technique taught
- FTU demonstrated (most commonly missed Tasks mark)
- TCS potency appropriate: betamethasone 0.1% arms/body; hydrocortisone 1% face only
- Steroid phobia addressed with written action plan
- Occupational health referral; MRSA swab
- Eczema herpeticum safety-net given
- Embarrassment at work acknowledged
- Steroid phobia validated; then addressed with evidence
- Occupational context acknowledged with practical plan
- Written action plan offered as patient empowerment
- Eczema herpeticum named specifically; not generic
Who you are
Amara Mensah, 34, healthcare assistant in a care home for the past 3 years. Known atopic eczema since early childhood. Previous mild disease mostly controlled with occasional hydrocortisone 1% and emollient. 4-week flare — worst on both arms; neck; and hands. Hands particularly bad (she washes her hands at least 30 times per day at work). Has run out of prescribed emollient 3 weeks ago; switched to “E45 from Boots” (insufficient). Using leftover hydrocortisone 1% on face and body but applying only a very thin smear (steroid phobia from mother’s experience). Embarrassed and self-conscious about her arms at work — wearing long sleeves in hot weather. POEM 16. PHQ-9 7 (low mood; not sleeping well due to itch).
Hidden agenda — disclose if GP asks specifically
Steroid phobia (disclose if GP asks about cream use or concerns): “My mum had a really bad experience with steroid cream — her skin went really thin and she got stretch marks. I don’t want that to happen to me. I’ve been putting on the thinnest layer I can. Is that OK?” Respond well if GP explains specifically when skin thinning occurs and when it doesn’t; and when FTU is demonstrated: “Oh — I had no idea you needed that much. I have been using far too little. No wonder it hasn’t been working.”
Embarrassment (volunteer if asked about impact): “I have been wearing long sleeves at work even though it’s hot. I don’t want the residents or my colleagues to see it. I feel like people are judging me.”
Work concern (disclose if asked about occupation): “I have to wash my hands so many times at day at work — the care home uses a very strong antibacterial soap. My hands are the worst part. Is that making it worse?” Respond well if GP identifies occupational trigger and refers to occupational health: “I didn’t know I could see an occupational health person for this.”
Responses to key conversations
- On FTU demonstration: “Oh — that is so much more than I have been using. I have been using a tiny amount because of what mum said. So all this time I have been using too little?”
- On written action plan: “This is really helpful — so I know exactly what to do next time without having to wait for an appointment? I really needed something like this.”
- On occupational health: “I did not know I could be referred for this. Can my employer make me use different products? Because the soap at work is really strong.”
- Challenge: “I am really worried about using the stronger cream. Can’t I just keep using the mild one but use more of it? I don’t want to risk making my skin worse.”
Clinical details
- Age 34; 4-week bilateral arm; neck; hand eczema flare; POEM 16; PHQ-9 7
- No fever; no rapidly spreading monomorphic vesicles (eczema herpeticum absent)
- Hands: bilateral; dorsa and fingers; moderate erythema; some weeping on web spaces; no honey-coloured crusting (minimal infection signs — send swab; unclear on examination)
- No skin atrophy or telangiectasia from previous TCS (using so little; no atrophy risk)
- Known house dust mite sensitivity (has feather pillows — potential trigger)
Resolution: Mrs. Mensah accepts the plan if the GP: acknowledges the steroid fear without dismissing it; explains specifically when skin thinning occurs and when it does not (2-week course of betamethasone on arms = safe); demonstrates the FTU and shows her how much cream she has actually been applying (too little); provides a written action plan; and explains that under-applying is causing the treatment failure. She leaves saying: “I had no idea I needed to use that much. I feel like I finally understand why it hasn’t been working.”
- Eczema herpeticum: punched-out vesicles; fever; rapid spread → 999; IV aciclovir
- Erythroderma (>90% BSA) → same-day hospital
- Sepsis from superinfection → 999
- Bacterial superinfection: fusidic acid or flucloxacillin; treat infection FIRST
- Severe eczema POEM ≥17: urgent dermatology
- Mild (POEM 3–7): emollient + hydrocortisone 1% 14 days
- Moderate (POEM 8–16): emollient + moderate-potent TCS 14 days; FTU; written plan
- Maintenance: emollient daily + proactive TCS ×2/week prone areas
| PETS | Parameter | Timing | Action |
|---|---|---|---|
| POEM | 7-item score 0–28 | Every review; target ≥3-point reduction | Not improving at 6–8 weeks: dermatology. Worsening: consider infection; incorrect TCS potency; steroid phobia |
| Emollient | Prescription request rate; POEM Q7 (dryness) | Every review | Not requesting refills: review adherence. Q7 not improving: frequency inadequate |
| TCS | POEM Q1 (itch); skin atrophy; telangiectasia; striae | 4–6 week review; annually if proactive regimen | Atrophy: reduce potency; switch to TCI. POEM not improving: dermatology. Clear skin: step down to proactive ×2/week |
| Superinfection | Crusting; weeping; pustules; rapidly spreading area | Every visit | Infection: Fucidin 7 days or flucloxacillin; treat first; then TCS. Herpeticum features: 999 |