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NICE CG57

John Montgomery8 min read

NICE CG57

NICE CG57, Atopic eczema in under 12s: diagnosis and management, is the guideline NICE publishes for children in England and Wales. It first appeared in 2007, was amended in 2023 (emollient bath additives) and was last updated on 22 September 2025, when the complementary-therapy recommendation was amended. Most recommendations are still labelled [2007], so much of the evidence base is close to 20 years old. Diagnosis follows UK Working Party Criteria: itchy skin plus three or more features, with cheeks and extensor surfaces counted for infants up to 18 months. Severity is graded clear, mild, moderate or severe, alongside a separate quality-of-life grading, and tools such as POEM are suggested. The quality standard QS44 turns key recommendations into measurable statements, for example 250–500 g a week of unperfumed emollient.

NICE [part-of] NICE CG57 NICE CG57 [defines] Atopic Dermatitis UK Working Party Criteria [part-of] NICE CG57 POEM [part-of] NICE CG57

The core of CG57 is the Stepped Care Approach (recommendation 1.5.1.1, table 2). Emollient Therapy is “the basis of management” and should always be used, even when the skin is clear. Treatment is then stepped up or down with severity: mild eczema gets emollients plus mild-potency Topical Corticosteroids; moderate eczema gets moderate-potency TCS, Topical Calcineurin Inhibitors or bandages; severe eczema gets potent TCS, TCIs, bandages, Phototherapy or systemic therapy. TCS potency matches severity. On the face and neck only mild TCS is used, except for 3–5 days of moderate potency in a severe flare. Moderate or potent TCS go on the axillae and groin for 7–14 days only. Potent TCS are not used under 12 months without specialist supervision, and very potent TCS are never used in children without specialist advice. Application is once or twice daily. For children with 2–3 flares a month, Weekend Therapy (2 consecutive days a week on problem areas) can be considered, with a review within 3–6 months. Emollient Bath Additives should not be offered (2023, after the BATHE Trial).

NICE CG57 [defines] Stepped Care Approach Emollient Therapy [part-of] Stepped Care Approach Topical Corticosteroids [part-of] Stepped Care Approach NICE CG57 [supports] Weekend Therapy BATHE Trial [supports] NICE CG57 NICE CG57 [opposes] Emollient Bath Additives

CG57 refers to technology appraisal TA82 (2004) on Topical Calcineurin Inhibitors. They are not first-line treatment and are not for mild eczema. Tacrolimus is a second-line option for moderate–severe eczema, and Pimecrolimus for moderate facial or neck eczema, in children aged 2 and over whose eczema TCS have not controlled, where further TCS risk serious effects such as irreversible Skin Atrophy. They should be started only with specialist dermatological advice, and not used under occlusion (bandages or dressings) without specialist advice. Wet Wrap Therapy and other whole-body occlusive dressings or bandages are never first-line. They should be started by a trained professional. When combined with TCS they are used for 7–14 days first and continued longer only with specialist advice. Dressings must not be used on infected eczema. CG57 says not to use Oral Antihistamines routinely. It allows a 1-month trial of a non-sedating antihistamine in severe eczema or severe itch or urticaria. A 7–14-day trial of a sedating antihistamine is allowed during flares for children aged 6 months and over when sleep disruption is significant.

NICE CG57 [regulates] Topical Calcineurin Inhibitors NICE CG57 [regulates] Wet Wrap Therapy NICE CG57 [opposes] Oral Antihistamines Skin Atrophy [relates] Topical Corticosteroids

On infection, CG57 asks clinicians to teach families to recognise Staphylococcus aureus and streptococcal infection, and to replace emollients that may be contaminated. Suspected Eczema Herpeticum needs immediate systemic Aciclovir and same-day specialist referral (same-day ophthalmology too if around the eyes). Antibiotic choice for Infected Eczema has since moved to NICE NG190. On Food Allergy, CG57 says to consider it only after immediate reactions, or in infants and young children whose moderate–severe eczema stays uncontrolled. It advises against high-street allergy tests. An exclusion trial is only for strongly suspected allergy, with a dietitian if a child is milk-free for more than 8 weeks. CG57 also warns that topical corticosteroids are deliberately added to some herbal products for children (Adulterated Herbal Creams). It notes that some Chinese Herbal Medicine has been linked to liver toxicity, and says homeopathy, herbal medicine, massage and supplements have not been adequately assessed in trials.

NICE CG57 [regulates] Eczema Herpeticum NICE NG190 [precedes] Infected Eczema NICE CG57 [regulates] Elimination Diets NICE CG57 [opposes] Adulterated Herbal Creams NICE CG57 [opposes] Chinese Herbal Medicine

Unregulated "natural" creams

CG57 tells parents to be cautious about herbal products for children, especially if not labelled in English, because some contain undeclared topical corticosteroids. Parents should keep using emollients with any complementary therapy and tell their clinician.

Referral rules (section 1.7) set the escalation points relevant to toddlers. Suspected eczema herpeticum needs a same-day referral. Urgent referral (within 2 weeks) is needed for severe eczema not responding to optimal topical therapy after 1 week, or when treatment of bacterial infection fails. Routine referral covers an uncertain diagnosis, poor control (for example 1–2 weeks of flares a month), facial eczema not responding to treatment, suspected Allergic Contact Dermatitis, significant sleep or psychosocial impact, recurrent severe infections, or faltering growth. Children with moderate–severe eczema and suspected food allergy go to specialist allergy services.

NICE CG57 [regulates] Allergic Contact Dermatitis NICE CG57 [relates] American Academy of Dermatology

Currency check (October 2026). The CG57 overview page (accessed 3 October 2026) still gives “Last reviewed: 22 September 2025”. The guideline will next be reviewed only “if there is new evidence that is likely to change the recommendations”. No replacement guideline or full update is announced. The September 2025 surveillance amended rec 1.5.1.45 [2007, amended 2025]. Families should now be told that homeopathy, herbal medicine, massage and food supplements have not been adequately assessed. They should also be told there is no evidence of benefit from fewer baths or showers (Bathing Frequency), ion-exchange water softeners (Hard Water; cf. SWET Trial) or silk clothing (Clothing and Fabrics; cf. CLOTHES Trial). Rec 1.6.1.1 now links to Eczema Care Online. Minor changes since then: May 2025, links to TA81/TA82 updated; August 2026, the link to the algorithm removed. CG57 still does not cover the newer non-steroid creams (Crisaborole, Ruxolitinib Cream, Roflumilast Cream, Tapinarof Cream) or biologics for under-12s. In the UK most of these are either unlicensed for young children or unlicensed altogether (see each note). By contrast, the US AAD Pediatric Guideline 2026 (April 2026) gives strong recommendations for them.

NICE CG57 [relates] AAD Pediatric Guideline 2026 NICE CG57 [relates] Hard Water Eczema Care Online [part-of] NICE CG57

Conflict: [NICE CG57, 2007 rec / TA82 2004] restricts Pimecrolimus to children aged 2 and over as second-line therapy. [National Eczema Society factsheet, reviewed Nov 2023] states UK licensing of Elidel from 3 months. Unresolved: the TA82 wording predates the licence change. Added to open_questions.

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