Referral criteria from primary care - atopic eczema in children

SIGN state (1):

• an emergency referral to a dermatologist or paediatrician should be arranged by telephone where there is clinical suspicion of eczema herpeticum
• 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.

NICE have made guidance with respect to children with atopic eczema (2,3)

Most children with atopic eczema can be managed in primary care. They should, however, be referred to a specialist service if (2):

****severe infection with herpes simplex (eczema herpeticum) is suspected

*** the disease is severe and has not responded to appropriate therapy in primary care

*** the rash becomes infected with bacteria (manifest as weeping, crusting, or the development of pustules), and treatment with an oral antibiotic plus a topical corticosteroid has failed

** the rash is giving rise to severe social or psychological problems; prompts to referral should include sleeplessness and school absenteeism

** treatment requires the use of excessive amounts of potent topical corticosteroids

* management in primary care has not controlled the rash satisfactorily. Ultimately, failure to improve is probably best based upon a subjective assessment by the child or parent

for example, the child is having 1-2 weeks of flares per month or is reacting adversely to many emollients (3)

* the patient or family might benefit from additional advice on application of treatments (bandaging techniques)

* contact dermatitis is suspected and confirmation requires patch-testing (this is rarely needed)

* dietary factors are suspected and dietary control a possibility

+ the diagnosis is, or has become, uncertain

Key to referral times:

**** immediate referral (a)

*** urgent referral (b)

** soon (b)

* routine (b)

+ times will be discretionary and depend on clinical circumstances

(a) within a day.

(b) Health authorities, trusts and primary care groups should work to local definitions of maximum waiting times in each of these categories. The multidisciplinary groups considered that a maximum waiting time of 2 weeks is appropriate for the urgent category.

Reference:

1. SIGN (March 2011). Management of atopic eczema in primary care.
2. NICE (May 2000). Referral Practice A guide to appropriate referral from general to specialist services.
3. NICE (December 2007).Atopic eczema in children Management of atopic eczema in children from birth up to the age of 12 years.