Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Diagnosis, Referral and Patient Education
D - An emergency referral to a dermatologist or paediatrician should be arranged by telephone where there is clinical suspicion of eczema herpeticum (widespread herpes simplex).
D - Patients should be referred to a dermatologist where there is:
- Uncertainty concerning the diagnosis
- Poor control of the condition or failure to respond to appropriate topical treatments
- Psychological upset or sleep problems
- Recurrent secondary infection
C - Patients with atopic eczema should have ongoing treatment with emollients.
Topical Corticosteroid Therapy
A - Patients should be advised to continue with emollient therapy during treatment with topical corticosteroids.
Once versus Twice Daily Application
B - Patients with atopic eczema should be advised to apply topical corticosteroids once daily.
A - Twice weekly maintenance therapy with a topical corticosteroid should be considered in patients with moderate to severe atopic eczema experiencing frequent relapses.
B - Topical corticosteroids should be used with caution in the periocular region.
Topical Calcineurin Inhibitors
C - Topical tacrolimus should be considered, in patients aged two years and older, for short term, intermittent treatment of moderate to severe atopic eczema that has not been controlled by topical corticosteroids or where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly skin atrophy.
Effectiveness of Antimicrobial Measures
B - Oral antibiotics are not recommended in the routine treatment of non-infected atopic eczema.
Food Allergy and Dietary Exclusion
C - Dietary exclusion is not recommended for management of atopic eczema in patients without confirmed food allergy.
Maternal Food Antigen Avoidance
A - The exclusion of foods during pregnancy and breast feeding to prevent the development of atopic eczema in infants is not recommended.
B - Parents should be advised that exclusive breast feeding for three months or more may help prevent the development of infant eczema where there is a family history of atopy.
B - Hydrolysed formulas should not be offered to infants in preference to breast milk for the prevention of atopic eczema.
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 randomised controlled trial (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
B: A 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+
C: A 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++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
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, e.g., case reports, case series
4: Expert opinion