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When to Refer

John Montgomery6 min read

When to Refer

Most toddler eczema is managed in primary care with Emollient Therapy and Topical Corticosteroids under the Stepped Care Approach. Referral is the top of that ladder. The clearest rules come from NICE CG57 section 1.7, which sorts referral into three speeds. Same day: suspected Eczema Herpeticum (rapidly worsening painful eczema, clustered blisters, punched-out erosions). NICE CKS calls for immediate hospital admission, and NICE quality standard QS44 adds that systemic Aciclovir should be started straight away, with same-day ophthalmology and dermatology advice if the skin around the eyes is involved. Urgent (within 2 weeks): severe eczema that has not responded to optimal topical therapy after 1 week, or bacterially Infected Eczema whose treatment has failed. Routine: everything else on the list below. These recommendations are all labelled [2007], so they are expert consensus rather than trial-derived.

NICE CG57 [defines] When to Refer When to Refer [part-of] Stepped Care Approach Eczema Herpeticum [precedes] When to Refer Infected Eczema [precedes] When to Refer

Same-day red flags in a toddler

Sudden painful worsening, clusters of small blisters or punched-out sores, fever or a floppy, unwell child with eczema can mean Eczema Herpeticum. This is an emergency: go to a doctor or emergency department the same day. Do not wait for a routine appointment, and do not put steroid cream on the sores in the meantime without medical advice.

Routine dermatology referral (NICE CG57 rec 1.7.1.3) is advised when: the diagnosis is uncertain; the eczema is not controlled in the parents’ own judgement (for example 1–2 weeks of flares a month, or reactions to many emollients); facial eczema has not responded; the family would benefit from specialist teaching such as bandaging or Wet Wrap Therapy; Allergic Contact Dermatitis is suspected (persistent eczema, or eczema on the face, eyelids or hands); the eczema is causing significant sleep or psychosocial problems (Sleep Disturbance in Eczema); or there are severe recurrent infections such as deep abscesses or pneumonia. If the eczema is controlled but the child’s or family’s quality of life is not, NICE (rec 1.7.1.4) and CKS advise referral for psychological support. A child who is not growing along their expected centile is referred for growth advice (rec 1.7.1.6). The South African paediatric algorithm (Kannenberg 2020) gives a shorter list for South Africa: refer to a dermatologist, paediatrician or allergist for moderate-to-severe or refractory eczema, frequent flares, coexisting immediate-type food allergy, or a poor response to treatment.

When to Refer [relates] Allergic Contact Dermatitis When to Refer [relates] Sleep Disturbance in Eczema When to Refer [relates] Wet Wrap Therapy South African Eczema Guidance [supports] When to Refer

Allergy referral is narrower. NICE CG57 rec 1.7.1.5 refers children with moderate or severe eczema and suspected Food Allergy for specialist investigation, and CKS adds that a paediatrician, immunologist or dermatologist should be involved when primary care lacks the expertise. The American Academy of Dermatology (summarising the 2010 NIAID guideline) suggests allergy evaluation for milk, egg, peanut, wheat and soy in children under 5 with moderate-to-severe eczema only if it persists despite optimised topical treatment, or if there is a reliable history of an immediate reaction to a food. The 2017 NIAID peanut addendum, based on the LEAP Trial, asks that infants with severe eczema and/or egg allergy be assessed (peanut sIgE or Skin Prick Testing) before peanut is introduced at 4–6 months. All these sources warn against broad screening panels, because a positive test without symptoms leads to unnecessary Elimination Diets. In Cape Town about 40% of children at a tertiary dermatology clinic with moderate-to-severe, therapy-resistant eczema had IgE-mediated food allergy, mostly egg and peanut (Kannenberg 2020).

NICE CG57 [regulates] Food Allergy American Academy of Dermatology [regulates] Food Allergy LEAP Trial [supports] When to Refer When to Refer [opposes] Elimination Diets

Don't start an elimination diet while waiting for referral

Cutting out milk, egg, wheat or other staples on the strength of a high-street or online allergy test can leave a toddler short of protein, calcium and energy, and delayed introduction may itself raise the risk of true food allergy. NICE asks for a dietitian if a child is milk-free for more than 8 weeks.

What happens at the specialist appointment depends on the question being asked. A dermatologist confirms the diagnosis, grades severity (often with SCORAD, EASI or POEM), checks for infection and steroid side effects, and reviews how much emollient and steroid is actually being used. Many families are found to be under-treating because of Steroid Phobia. Suspected contact allergy leads to Patch Testing, which for toddlers uses a custom panel plus the family’s own products. Suspected food allergy leads to an allergy clinic for Skin Prick Testing or specific IgE and, where results are unclear, an Oral Food Challenge. Specialist services may also teach Wet Wrap Therapy, start Topical Calcineurin Inhibitors (NICE TA82 says these should be started only by doctors, including GPs, with a special interest and experience in dermatology) and, for severe disease, consider Phototherapy, Systemic Immunosuppressants or Dupilumab. Many UK clinics include an eczema specialist nurse or a group education session. The Cochrane review by Ersser (2014) found some evidence that multiprofessional programmes and nurse-led clinics improve severity and quality of life, and parents usually leave with a Written Eczema Action Plan.

When to Refer [precedes] Patch Testing When to Refer [precedes] Oral Food Challenge When to Refer [precedes] Eczema Education Programmes Steroid Phobia [worsens] Atopic Dermatitis Cochrane [supports] Eczema Education Programmes

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