Stepped Care Approach
The stepped care approach is the management framework in NICE CG57 (rec 1.5.1.1, table 2). Emollient Therapy is used at every level, even when the skin is clear, and treatment is stepped up or down with severity. Mild eczema gets mild Topical Corticosteroids. Moderate eczema gets moderate TCS, Topical Calcineurin Inhibitors or bandages. Severe eczema gets potent TCS, TCIs, bandages, Phototherapy or systemic therapy (Systemic Immunosuppressants, Dupilumab). Once the flare settles, treatment steps back down. Children with 2–3 flares a month can be moved to Weekend Therapy maintenance.
NICE CG57 [defines] Stepped Care Approach Emollient Therapy [part-of] Stepped Care Approach Topical Corticosteroids [part-of] Stepped Care Approach Weekend Therapy [part-of] Stepped Care Approach
The model only works if parents know when to step. NICE CG57 rec 1.6.1.1 asks clinicians to teach “when and how to step treatment up or down” with verbal and written information and demonstrations. In practice that means a Written Eczema Action Plan, ideally backed by an eczema education programme. The top of the ladder is specialist referral. NICE section 1.7 sets same-day, urgent (2-week) and routine triggers, set out in When to Refer. Steps from TCIs upward (bandages, phototherapy, systemics) are normally started by specialists.
Written Eczema Action Plan [part-of] Stepped Care Approach Eczema Education Programmes [supports] Stepped Care Approach When to Refer [part-of] Stepped Care Approach
The South African paediatric algorithm (South African Eczema Guidance, Kannenberg 2020) uses the same logic for mild-to-moderate disease, with one difference. In sensitive areas (face, eyelids, folds) a TCI is the first step rather than a mild TCS. Severe disease goes straight to a specialist. Proactive maintenance (TCS or TCI 2–3 times a week plus emollients) is used for four or more flares a year.
South African Eczema Guidance [relates] Stepped Care Approach Topical Calcineurin Inhibitors [part-of] Stepped Care Approach
Connections
- NICE CG57 — defines the model, source: NICE CG57
- Emollient Therapy — base of every step, source: NICE CG57
- Topical Corticosteroids — potency matched to step, source: NICE CG57
- When to Refer — referral is the top step (NICE section 1.7), source: NICE CG57
- Written Eczema Action Plan — tells parents when to step up/down, source: NICE CG57 rec 1.6.1.1
- Eczema Education Programmes — teach stepping decisions, source: NICE CG57; Ersser 2014
- South African Eczema Guidance — SA algorithm variant with TCI first on sensitive sites, source: Kannenberg 2020
- Weekend Therapy — maintenance step for frequent flares, source: NICE CG57