Dermatology for MRCGP AKT

A 4-year-old girl has itchy, dry patches in the creases of both elbows and behind both knees. On her dark brown skin the patches look darker brown to grey, rough and thickened, with scratch marks. She wakes most nights scratching. She uses an unperfumed emollient twice a day. A 1% hydrocortisone ointment for flares has helped very little. According to current NICE guidance, which is the most appropriate treatment to add?

1. An urgent referral to dermatology, to be seen within 2 weeks Wrong. She has not yet had optimal topical treatment. Urgent referral is for severe eczema that fails 1 week of optimal treatment, or for infection that does not clear.
2. Continue 1% hydrocortisone for a longer course Wrong. Mild-potency steroid is for mild eczema. It has already failed her, so a longer course will not fix the problem.
3. A very potent topical corticosteroid, such as clobetasol propionate Wrong. NICE says not to use very potent steroids in children without specialist dermatology advice. Her eczema is moderate, not severe.
4. A moderate-potency topical corticosteroid, such as clobetasone butyrate 0.05% correct Correct. Itchy, thickened, scratched flexural skin with poor sleep is moderate eczema. NICE pairs moderate eczema with moderate-potency steroids on top of daily emollients.
5. A topical calcineurin inhibitor, such as tacrolimus Wrong. This is a second-line choice for moderate to severe eczema that steroids have not controlled. She has only tried a mild steroid, so the next step is a stronger steroid.

The point: NICE uses a stepped plan for children. Mild eczema gets emollients and a mild steroid. Moderate eczema gets a moderate-potency steroid, and sometimes a calcineurin inhibitor or bandages. Severe eczema gets a potent steroid. Emollients stay at every step. On darker skin, eczema often looks dark brown, grey or purple, and the skin may stay lighter or darker for months after it clears.

Source: NICE CG57: Atopic eczema in under 12s: diagnosis and management NICE · tier 1, national regulator or guidance

A 3-year-old boy with known eczema has been unwell for 2 days with a temperature of 38.9°C. Over the same time, the eczema on his face and neck has worsened fast. There are clusters of small, identical blisters and shallow, punched-out sores with crusts. On his brown skin the sores look dark red to purple-brown. They are painful. He is irritable and eating poorly. Fusidic acid cream prescribed last week has not helped. According to current NICE guidance, which is the most appropriate management?

1. Take a skin swab and treat when the result is back Wrong. A swab helps later, but the result takes days. Treatment must not wait for it.
2. Oral flucloxacillin and review in 48 hours Wrong. Antibiotics do not treat a virus. Clustered blisters and punched-out sores with fever point to herpes simplex, and a 48-hour delay risks spread, eye damage and sepsis.
3. Refer urgently to dermatology, to be seen within 2 weeks Wrong. Two weeks is for severe eczema that has not responded to treatment. Suspected eczema herpeticum needs same-day advice.
4. A stronger topical steroid and review in 1 week Wrong. A stronger steroid on active herpes simplex can make it spread. It also ignores his fever.
5. Start systemic aciclovir and refer for same-day specialist dermatology advice correct Correct. This looks like eczema herpeticum, which is herpes simplex spreading through eczema skin. NICE says start systemic aciclovir at once and arrange same-day specialist advice.

The point: Think of eczema herpeticum when eczema suddenly worsens, becomes painful, and shows clusters of blisters or punched-out sores, often with fever. Start systemic aciclovir immediately and refer the same day. If the skin around the eye is involved, ask for same-day eye and skin advice. Add an antibiotic only if bacterial infection is also suspected. On darker skin the sores can look dark red, purple or brown.

Source: NICE CG57: Atopic eczema in under 12s: diagnosis and management NICE · tier 1, national regulator or guidance

A 7-year-old girl with eczema has had a flare in both elbow creases for 5 days. Two small patches ooze clear fluid and have honey-coloured crusts. On her dark brown skin the surrounding eczema looks grey-purple. She is well, has no fever and is eating and playing normally. She has run out of her moderate-potency steroid. There are no blisters or punched-out sores. According to current NICE guidance, which is the most appropriate management?

1. Oral aciclovir Wrong. Aciclovir is for eczema herpeticum. She has no clustered blisters, punched-out sores or fever.
2. A skin swab before any treatment is started Wrong. NICE says do not routinely swab at first presentation of secondary bacterial infection of eczema.
3. Oral flucloxacillin for 7 days Wrong. She is not systemically unwell and the infection is small. NICE says oral antibiotics are for widespread or severe infection, or for a child who is unwell.
4. Fusidic acid 2% cream three times a day for 5 to 7 days Wrong. This is the topical choice only if an antibiotic is used. NICE says do not routinely offer a topical or oral antibiotic to a well child, because the benefit is small and resistance builds.
5. Treat the flare with emollients and a topical corticosteroid, and do not routinely give an antibiotic correct Correct. Weeping and crusts do not always mean infection needing antibiotics. For a well child, treating the eczema itself is the right step. Advise the family to return if she worsens fast.

The point: Signs that may mean infected eczema are weeping, pustules, crusts, no response to treatment, fast worsening, fever and feeling unwell. NICE says not to routinely swab and not to routinely give antibiotics to a person who is well. Treat the flare with emollients and steroid whether or not an antibiotic is used. Use an oral antibiotic if the person is systemically unwell. Consider herpes simplex if the eczema does not respond.

Source: NICE NG190: Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing NICE · tier 1, national regulator or guidance