Quality standard

Quality statement 2: Stepped approach to management

Quality statement 2: Stepped approach to management

Quality statement

Children with atopic eczema are offered treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Rationale

Atopic eczema is typically an episodic condition consisting of flares and remissions, though in some children it is continuous. Treatment for atopic eczema should be tailored, with treatments stepped up and down according to the recorded severity of symptoms. Areas of atopic eczema of differing severity can coexist in the same child, and each area should be treated independently. The stepped-care plan involves self-management and adherence to treatment, therefore healthcare practitioners should give children with atopic eczema and their families or carers support and information on when and how to step treatment up or down.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Structure

Evidence of local arrangements to ensure that children with atopic eczema are offered treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from written clinical protocols.

Process

a) The proportion of children with atopic eczema who have their eczema severity recorded at each eczema consultation.

Numerator – the number of children in the denominator who have their eczema severity recorded at each eczema consultation.

Denominator – the number of eczema consultations with children with atopic eczema.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

b) The proportion of children with atopic eczema who receive treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Numerator – the number of children in the denominator who receive treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Denominator – the number of children with atopic eczema.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

What the quality statement means for different audiences

Service providers ensure that systems are in place to offer children with atopic eczema treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Healthcare practitioners offer children with atopic eczema treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Commissioners ensure that they commission services with local arrangements to offer children with atopic eczema treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Children with atopic eczema are offered treatment using a stepped-care plan (which means that treatments are added or stopped depending on how severe the eczema is) and given advice and information about atopic eczema and its treatment.

Source guidance

Atopic eczema in under 12s: diagnosis and management. NICE guideline CG57 (2007, updated 2023), recommendations 1.2.1.1, 1.2.1.3 and 1.5.1.1

Definitions of terms used in this quality statement

Eczema severity

An assessment of the physical severity of atopic eczema and the impact of atopic eczema on quality of life and social wellbeing is recommended at each eczema consultation. Physical severity of atopic eczema is defined as follows:

  • Clear: normal skin, no evidence of active atopic eczema.

  • Mild: areas of dry skin, infrequent itching (with or without small areas of redness).

  • Moderate: areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening).

  • Severe: widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation).

[Adapted from NICE's guideline on atopic eczema in under 12s, recommendation 1.2.1.1]

Stepped approach to management

Healthcare practitioners should use a stepped approach to managing atopic eczema in children, which means tailoring the treatment step to the severity of the atopic eczema. Emollients should form the basis of atopic eczema management and should always be used, even when the atopic eczema is clear. Management can then be stepped up or down, according to the severity of symptoms, by adding or withdrawing treatments as follows (phototherapy and systemic therapy should be undertaken only under specialist dermatological supervision by staff who are experienced in dealing with children).

Stepped treatment options

Mild atopic eczema:

  • emollients

  • mild-potency topical corticosteroids.

Moderate atopic eczema:

  • emollients

  • moderate-potency topical corticosteroids

  • topical calcineurin inhibitors

  • bandages.

Severe atopic eczema:

  • emollients

  • potent topical corticosteroids

  • topical calcineurin inhibitors

  • bandages

  • phototherapy

  • systemic therapy.

Healthcare practitioners should review repeat prescriptions of individual products and combinations of products with children with atopic eczema (and their parents or carers) at least once a year to ensure that treatment remains optimal. [Adapted from NICE's guideline on atopic eczema in under 12s, recommendations 1.5.1.1, 1.5.1.8 and 1.5.1.45]

Supported by education

Education on the use of, and adherence to, treatment is essential to the stepped-care plan approach. Healthcare practitioners should offer children with atopic eczema (and their parents or carers) information on how to recognise the symptoms and signs of bacterial infection and also how to recognise and manage flares of atopic eczema according to the stepped-care plan. Healthcare practitioners should spend time educating children with atopic eczema (and their parents or carers) about atopic eczema and its treatment. They should provide information in verbal and written forms, with practical demonstrations, and should cover:

  • how much of the treatments to use

  • how to apply and how often to apply prescribed treatments, including emollients, steroids, calcineurin inhibitors and medicated dressings (bandages)

  • when and how to step treatment up or down

  • how to treat infected atopic eczema.

This should be reinforced at every consultation, addressing factors that affect adherence. [Adapted from NICE's guideline on atopic eczema in under 12s, recommendations 1.5.1.2, 1.5.1.38 and 1.6.1.1]

Equality and diversity considerations

Healthcare practitioners should be aware of the potential difficulties of assessing eczema severity in children with darker skin tones.

In recommending skin treatments, healthcare practitioners should be sensitive to the cultural practices of families or carers of children with atopic eczema. For example, if families or carers use olive oil as a skin treatment (which is likely to be harmful to a child's skin) or if they rinse children after bathing (rinsing off emollients), the reasons for using the recommended treatment and applying it correctly should be explained sensitively.