South African Eczema Guidance

South Africa’s eczema guidance comes in three layers. In 2008 a five-dermatologist working group of the Dermatological Society of South Africa (Sinclair, Aboobaker, Jordaan, Modi, Todd) published consensus guidelines for adolescents and adults in the SAMJ. In October 2014 the SAMJ ran a CME issue, introduced by W Sinclair (dermatology, Free State) and RJ Green (paediatrics, Pretoria), setting out the all-ages “Guidelines on the management of atopic dermatitis in South Africa” (Sinclair, Aboobaker, Green et al., posted online 2015). Paediatric allergists linked to the Allergy Society of South Africa (ALLSA) contributed to the series alongside dermatologists. In 2020 a 12-expert panel (Kannenberg et al., South African Family Practice) published a practical algorithm for mild-to-moderate paediatric eczema, written for GPs and nurse practitioners because “most patients in South Africa have no access to specialist healthcare”. No full 2019 or 2021 rewrite of the national guideline was found. The 2020 algorithm still cites the 2015 guideline as current, so it is the de facto update. Its medical-writing support was funded by Mylan (maker of a TCI), which should be weighed when reading its TCI advice.

Dermatological Society of South Africa [defines] South African Eczema Guidance Allergy Society of South Africa [part-of] South African Eczema Guidance South African Eczema Guidance [defines] Atopic Dermatitis South African Eczema Guidance [relates] NICE CG57

The clinical content mostly matches NICE CG57 and European guidance. Diagnosis uses the UK Working Party Criteria, or revised versions or Hanifin-Rajka Criteria in infants. The 2019 sub-Saharan Africa position statement notes that the UK criteria had poor positive predictive value when tested in South Africa and Ethiopia. The guidance also stresses that Black African children often show extensor and perifollicular eczema rather than the classic flexural pattern. Everyone uses a fragrance-free emollient at least twice daily. Mild-to-moderate flares on the body are treated with low- or moderate-potency Topical Corticosteroids once daily. Severe flares get moderate or potent TCS, with Fingertip Unit dosing. Children with four or more flares a year get proactive maintenance (Weekend Therapy-style TCS or TCI 2–3 times a week). The main departure from NICE is that, for flares on the face, eyelids and skin folds, the algorithm recommends a TCI twice daily as first line. TCS are used there only when a TCI is unavailable.

South African Eczema Guidance [supports] Emollient Therapy South African Eczema Guidance [supports] Topical Calcineurin Inhibitors South African Eczema Guidance [supports] Weekend Therapy UK Working Party Criteria [part-of] South African Eczema Guidance

Conflict: [Kannenberg et al., SAFP 2020] recommends TCIs as first-line for mild-to-moderate flares in sensitive areas, and says experts consider Pimecrolimus safe under 2 years even though in SA it is registered only from age 2. [NICE CG57 / TA82, 2004–2007] says TCIs are not first-line, are for children 2 and over, and should be started with specialist advice. Unresolved — added to open_questions.

The local practice points matter most for families. Emollients and cost: public clinics mainly issue aqueous cream and emulsifying ointment. The Cape Town RCT by Hlela et al. (2015; 120 children aged 1–12 at Red Cross War Memorial Children’s Hospital) found emulsifying ointment, cetomacrogol, white petroleum jelly and a home-mixed glycerine:petroleum 1:2 blend equally effective. Fragrance-free baby oil (Mineral Oil) worked as well as aqueous cream as a soap substitute. The authors note that even cetomacrogol and emulsifying ointment are “not affordable for most of our patients”. The 2020 algorithm therefore endorses petroleum jelly or glycerine/petroleum when cost is a barrier. Aqueous Cream and emulsifying ointment are recommended only as wash products, never as leave-on moisturisers, because aqueous cream (containing Sodium Lauryl Sulfate) damages the skin barrier. Medicine access: TCS cost about R2.21/g (1% hydrocortisone) to R17.63/g. TCIs have “limited availability” in government tertiary and quaternary hospitals. In SA, Pimecrolimus is registered for mild-to-moderate eczema from age 2, and Tacrolimus 0.03% for moderate-to-severe eczema from age 2. The SAHPRA-approved Dupixent leaflet (revised May 2024) covers Dupilumab only from 6 years, and states that safety and benefit under 6 “are not yet known”. Biologics are “out of reach of most SSA public medical systems” (ISAD 2019).

SAHPRA [regulates] Dupilumab SAHPRA [regulates] Topical Calcineurin Inhibitors South African Eczema Guidance [supports] Petrolatum South African Eczema Guidance [opposes] Aqueous Cream Sodium Lauryl Sulfate [worsens] Skin Barrier Dysfunction

Conflict: [SAHPRA-approved Dupixent PIL, 13 May 2024] registers dupilumab for atopic dermatitis from 6 years and says safety and benefit under 6 are unknown. [FDA label 2022+/EMA EPAR] license it from 6 months. A South African toddler (1–4) would be off-label. Unresolved (a later SAHPRA amendment may exist) — added to open_questions.

Traditional remedies, skin-lighteners and setting: the 2020 algorithm notes that “a high proportion” of South African patients use complementary and alternative therapies, so it puts heavy weight on education. The 2019 ISAD sub-Saharan Africa position statement reports widespread self-medication with herbal products and consultation with traditional healers, driven by low cost, cultural acceptability and more time for dialogue. It recommends training traditional healers, as has been done for HIV prevention. It also warns that cheap topical corticosteroids are sold by street vendors and corner shops as skin-lightening creams of uncertain quality, which links to Adulterated Herbal Creams and Topical Steroid Withdrawal risk. On setting, eczema is far more common in cities: 23.5% of 1–3-year-olds in Cape Town versus 1.8% in the rural Eastern Cape. Prevalence among Cape Town adolescents rose from 1995 to 2002. In amaXhosa patients, filaggrin breakdown products are reduced without the European loss-of-function Filaggrin mutations. No SA-specific climate guidance was found beyond general advice to keep children cool, use cotton clothing and use non-irritating sunscreen. For education the guidance points families to the Allergy Foundation of South Africa’s leaflets and Child’s Eczema Action Plan (Written Eczema Action Plan). It also notes that ready-made wet-wrap garments are now sold locally (Wet Wrap Therapy), and that teledermatology is being used to reach rural clinics.

South African Eczema Guidance [opposes] Adulterated Herbal Creams South African Eczema Guidance [relates] Herbal and Home Remedies for Eczema South African Eczema Guidance [supports] Written Eczema Action Plan South African Eczema Guidance [supports] Eczema Education Programmes Filaggrin [relates] South African Eczema Guidance

Steroid "lightening" creams and unlabelled herbal mixes

In South Africa, cheap creams sold informally (street stalls, spaza shops, some traditional preparations) may contain undeclared or unknown-strength topical steroids. On a toddler’s face or nappy area these can cause skin thinning, steroid acne or rebound flares. Use only clinic- or pharmacy-dispensed products with a known strength, and tell the nurse or doctor about any traditional remedy being used.

Connections

• NICE CG57 — SA guidance broadly aligned; differs on first-line TCI for sensitive sites, source: Kannenberg 2020; NICE CG57
• Dermatological Society of South Africa — 2008 working-group authors, source: Sinclair et al SAMJ 2008
• Allergy Society of South Africa — allergy co-contributors; food-allergy consensus, source: Kannenberg 2020
• SAHPRA — registers TCIs and dupilumab (≥6 y), source: SAHPRA Dupixent PIL 2024
• Dupilumab — SA registration from 6 years only, source: SAHPRA PIL 2024
• Pimecrolimus — SA-registered ≥2 y, mild–moderate; first-line on face in algorithm, source: Kannenberg 2020
• Tacrolimus — SA 0.03% ≥2 y moderate–severe, source: Kannenberg 2020
• Topical Calcineurin Inhibitors — limited public-sector availability, source: Kannenberg 2020
• Topical Corticosteroids — SA potency list and cost per gram, source: Kannenberg 2020
• Petrolatum — affordable emollient equivalent to emulsifying ointment, source: Hlela 2015 SAMJ
• Mineral Oil — fragrance-free baby oil as soap substitute, source: Hlela 2015 SAMJ
• Aqueous Cream — wash-only, not leave-on, source: Kannenberg 2020; Hlela 2015
• Emollient Therapy — twice-daily fragrance-free emollient for all, source: Kannenberg 2020
• Adulterated Herbal Creams — informal TCS-containing lightening creams, source: ISAD SSA position statement 2019
• Herbal and Home Remedies for Eczema — high CAM and traditional-healer use, source: ISAD 2019; Kannenberg 2020
• Filaggrin — amaXhosa patients lack typical FLG mutations, source: ISAD 2019
• UK Working Party Criteria — used in SA but poorly validated in African skin, source: ISAD 2019
• Written Eczema Action Plan — Allergy Foundation SA Child’s Eczema Action Plan, source: Kannenberg 2020
• Eczema Education Programmes — education before therapy; nurse-practitioner training, source: Kannenberg 2020
• Wet Wrap Therapy — wet-wrap garments available locally, source: Kannenberg 2020
• When to Refer — SA referral criteria, source: Kannenberg 2020
• Food Allergy — ~40% IgE food allergy in refractory cases (Cape Town), source: Kannenberg 2020