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When to Get Help

Usual follow-up

Parents should contact a clinician when:

  • eczema is not improving with the agreed plan after 7-14 days
  • flares are becoming more frequent or more severe
  • sleep disruption is severe and persistent
  • the child needs stronger treatment repeatedly
  • parents are no longer confident the diagnosis is correct
  • there are signs of secondary infection

Signs that may suggest bacterial infection

Seek medical advice promptly if eczema becomes:

  • weepy (clear or yellow fluid)
  • crusted (especially golden or honey-coloured crusts)
  • pustular (small pus-filled spots)
  • rapidly more painful or inflamed
  • associated with fever or a child who seems unwell

Bacterial infection (usually Staphylococcus aureus) can make eczema suddenly much worse and needs different treatment. Oral antibiotics are more likely when infection is widespread, severe, or the child seems unwell; smaller localised areas may be managed differently. Do not apply occlusive wraps to infected skin.

Eczema herpeticum: a medical emergency

Learn to recognise this

Eczema herpeticum is a herpes simplex virus (HSV-1 or HSV-2) infection superimposed on eczematous skin. It spreads rapidly and can become life-threatening. Every eczema parent should know how to spot it. It is more common in children with moderate-to-severe AD and in those with elevated IgE levels.

How to recognise eczema herpeticum

  • Clusters of small painful blisters that look different from usual eczema flares; often described as "punched-out" sores with bloody or dark crusts
  • Rapid spread over hours to days, often starting on the face or head
  • The child looks unwell: fever, lethargy, poor feeding, swollen lymph nodes
  • Blisters may be concentrated on face/head/neck initially but can spread to trunk and limbs
  • It looks different from a regular flare: the blisters are more uniform, grouped, and painful rather than just itchy

Why it is urgent

  • Can progress to herpetic keratitis (eye infection risking vision loss)
  • Rarely, can spread to brain, lungs, or liver
  • Early antiviral treatment (acyclovir/aciclovir) is critical and dramatically improves outcomes; hospitalisation is usually required for young children (Leung et al., Pediatrics, 2018)
  • Delay increases the risk of serious complications

What parents should do

  1. Seek same-day urgent medical care — do not wait for a routine appointment
  2. If blisters are near the eyes, request urgent ophthalmology review
  3. Do not apply topical steroids or occlusive dressings to the suspected area
  4. Tell the clinician that your child has eczema and you suspect herpes infection
  5. Keep the child away from other children with eczema or newborns until assessed

Common parent experience

Parents on forums consistently report that eczema herpeticum was initially mistaken for a "bad flare," leading to delayed treatment. Learning the visual difference between herpes blisters and eczema flares is one of the most important safety skills for eczema parents.

Red flags that need urgent attention

Urgent medical review is important when there is:

  • rapidly spreading painful or blistering rash (possible eczema herpeticum)
  • eye pain, swelling around the eye, or change in vision
  • signs of dehydration or poor intake in a young child
  • a child who is lethargic, floppy, or looks seriously unwell
  • any symptoms suggesting anaphylaxis after food or medication exposure (wheezing, lip/tongue swelling, collapse)
  • extensive weeping, crusting, or pustules with fever

These problems should not be treated as routine eczema care at home.

When treatment is not working

If the child is not improving despite good routine care and correct use of prescribed treatment, the next question may not be "what stronger eczema product do we need?" It may be:

  • Is this really ordinary eczema? Ask the clinician to reconsider the diagnosis.
  • Is there allergic contact dermatitis? A reaction to an ingredient in creams, preservatives (especially methylisothiazolinone), or even the steroid itself. Patch testing can help.
  • Is there scabies? Consider if multiple household members are itchy.
  • Is there fungal infection? Ring-shaped lesions or areas resistant to steroids.
  • Is infection complicating the eczema? Bacterial or viral infection can make standard treatment ineffective.
  • Is treatment being used correctly? Enough product, correct strength, right duration, correct technique.

NICE recommends reviewing the diagnosis and/or referring to a specialist if moderate-to-severe disease remains uncontrolled after 1-2 well-executed cycles of guideline-consistent topical therapy.

Escalation to specialist care

Your clinician may discuss referral to a dermatologist or allergist if:

  • topical therapy is optimised but eczema remains moderate-to-severe
  • the child needs frequent courses of potent steroids
  • there are concerns about contact allergy (patch testing needed)
  • food allergy evaluation is warranted
  • systemic therapy may be needed

Systemic treatments available for children

For moderate-to-severe eczema not controlled by topical therapy, a growing number of systemic options now exist:

  • Dupilumab (Dupixent): biologic injection; approved for children from 6 months; targets IL-4/IL-13 inflammation. Parents frequently describe it as "life-changing" for quality of life.
  • Nemolizumab (Nemluvio): biologic injection targeting IL-31 (the itch cytokine); FDA approved December 2024 for ages 12 and older. AAD 2026 late-breaking data showed efficacy and safety in children aged 2 to 11, with sustained itch and skin improvement for up to a year.
  • Tralokinumab, Lebrikizumab: additional biologics available for adolescents 12 and older; trials underway for younger children.
  • JAK inhibitors (upadacitinib, abrocitinib, baricitinib): oral tablets; baricitinib now approved from age 2 in Europe, others from age 12. Require monitoring.
  • Phototherapy: UV light treatment; conditionally recommended by guidelines; requires regular clinic visits.
  • Cyclosporine, methotrexate: older immunosuppressants used in refractory cases under specialist supervision.

These require specialist prescription and monitoring. The treatment landscape has expanded dramatically since 2020 and continues to grow — the AAD 2026 meeting presented late-breaking data on several additional pipeline treatments, including an oral STAT6 degrader (KT-621) that may provide biologic-level efficacy without injections, and a trispecific antibody (tilrekimig) that blocks three inflammatory pathways at once. See Treatments and Solutions for the full 2026 pipeline overview.

Good questions for appointments

Parents can ask:

  • Does this still look like eczema, or could it be something else?
  • What is the plan for mild, moderate, and severe flares?
  • Which strength steroid, where, how often, and for how long?
  • What signs mean we should call the same day?
  • When should infection be suspected?
  • Which products or ingredients should we avoid?
  • Should we consider patch testing for contact allergy?
  • What is our threshold for referral to a specialist?
  • Can you provide a written action plan we can follow at home?

Preparing for appointments

Bring your tracking notes or log. Clinicians value:

  • a timeline of what happened and when
  • a list of what has been tried and what happened
  • photos of the rash at its worst (take photos during flares, not just at the appointment when skin may look better)
  • specific questions you want answered
  • a note of what concerns you most (itch, sleep, infection, appearance, emotional impact)

Key references

  • AAP. "Atopic Dermatitis: Clinical Practice Guideline." Pediatrics, 2025.
  • NICE CG57. "Atopic eczema in under 12s: diagnosis and management." Updated 2023.
  • NICE NG190. "Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing." Updated 2024.
  • Leung DY et al. "Eczema herpeticum." Pediatrics 141(3):e20173729, 2018.
  • EuroGuiDerm. "European guideline on atopic eczema — systemic therapy update." J Eur Acad Dermatol Venereol, 2024.
  • National Eczema Society. "Treatments for eczema." eczema.org

If the pattern feels wrong

Ask for diagnostic review if:

  • the child keeps worsening despite careful treatment
  • the rash behaves strangely or is in unusual areas
  • "treatment" seems to make the skin worse
  • several people in the household are itchy
  • the child has had multiple courses of antibiotics for skin infections

When eczema behaves in an unexpected way, it is reasonable to consider allergic contact dermatitis, scabies, fungal infection, or another skin condition. A specialist referral for patch testing or further evaluation may be the most useful next step.