Practice Based implementation advice
Atopic eczema in children
Published: September 2013, second edition
http://guidance.nice.org.uk/CG57
This implementation advice accompanies the NICE clinical guideline
(available online at: www.nice.org.uk/guidance/CG57).
It draws from the learning and experience of practitioners working in services
to provide support for users who may wish to develop an action plan to
implement certain aspects of the guideline. It is not NICE guidance.
This document includes example pathways and signposts to resources from
other organisations. While NICE is satisfied that they broadly support the
guideline at the point of publication of this document, NICE cannot be held
responsible for the content of resources produced by other organisations.
Refer to the NICE guideline for any queries or concerns about the relationship
between the NICE guideline and the example pathways or resources. Issue
date: 2013
National Institute for Health and Care Excellence
Level 1A
City Tower
Piccadilly Plaza
Manchester
M1 4BD
www.nice.org.uk
Implementation of the guidance is the responsibility of local commissioners
and/or providers. Commissioners and providers are reminded that it is their
responsibility to implement the guidance, in their local context, in light of their
duties to avoid unlawful discrimination and to have regard to promoting
equality of opportunity. Nothing in the guidance or this document should be
interpreted in a way which would be inconsistent with compliance with those
duties.
© National Institute for Health and Care Excellence, 2013. All rights reserved.
This material may be freely reproduced for educational and not-for-profit
purposes. No reproduction by or for commercial organisations, is allowed
without the express written permission of NICE.
Steps to implementing NICE clinical guidelines
The algorithm below outlines the process for implementing NICE clinical
guidelines. When using this advice online, hold down the ‘Ctrl’ button and click
on the hyperlinks in the boxes to go directly to the advice you need. The
advice has been developed in consultation with a range of experts from
patient and professional groups. A list of these contributors is available here.
Why implement this guideline?
Identify a clinical lead
Promote the guideline
Carry out a baseline assessment
Assess cost
Build an action plan
National support for local action
Sources of further information
Disseminate and implement plan
Sources of further information
Review and monitor
Share learning
3
Why implement this guideline?
Atopic eczema affects one in five children in the UK and can have a serious
impact on the child’s quality of life and psychosocial wellbeing. In over 80% of
cases the eczema can be managed in primary care.
NICE has published a Quality Standard for Atopic Eczema in Children.
NICE quality standards are a concise set of prioritised statements designed to
drive measurable quality improvements within a particular area of health or
care. NICE quality standards are central to supporting the Government's
vision for a health and social care system focused on delivering the best
possible outcomes for people who use services, as detailed in the Health and
Social Care Act (2012). Quality standards are reflected in the Clinical
Commissioning Group Outcome Indicator Set (CCGOIS) and inform payment
mechanisms and incentive schemes such as the Quality and Outcomes
Framework (QOF) and Commissioning for Quality and Innovation (CQUIN)
Payment Framework.
If the guideline is not relevant to your organisation, remember to record it.
Back to algorithm
4
Identify a clinical lead
If you are responsible for implementing NICE guidance (NICE manager) you
should identify a clinical lead to begin putting the guideline into practice.
The guideline is relevant to primary, secondary and community care and also
to practice in schools, nurseries and childcare establishments. The clinical
lead will need to liaise with people in these different settings. Someone from a
dermatology service or a primary care practitioner with a special interest in
eczema would be an appropriate clinical lead.
Back to algorithm
5
Promote the guideline
The NICE manager should ensure that all relevant groups are aware of the
guideline and have copies of the quick reference guide.
The slide set provided by NICE should help you raise awareness of the
guideline.
Back to algorithm
6
Carry out a baseline assessment
Using the published guideline, the clinical lead should work with the relevant
specialist group to compare current activity with the recommendations. This
information could be gathered through informal discussions or by using a
more formal questionnaire. This baseline assessment will help identify exactly
what your organisation and others are doing now and what needs to change
in light of the guideline.
Consider, for example, how the recommendations will have an impact on:
 training
 prescribing
The NICE audit support may help you with this process.
Who should be involved?
Once the baseline assessment has identified what needs to change, the next
stage is to identify which groups will need to alter their current way of working
and to consider the best way to engage them in the development and
implementation of the action plan. These groups are likely to include:
 service users and carers
 child psychologists
 commissioners
 dermatologists
 dermatology nurses
 general practitioners
 health visitors
 paediatric nurses
 paediatricians
 pharmacists
 practice nurses
 pre-school/nursery/school settings
 school nurses/school health teams
7
In most cases, there may be existing fora or networks of these staff that could
fulfil this function.
Back to algorithm
8
Assess cost
The NICE manager should work with the clinical lead to assess how much it
will cost to implement the guideline using the costing template provided by
NICE. It might be possible to make some of the required changes using
existing resources, and there may be potential for savings to be achieved, or
capacity freed up to be used for other things.
Click here to view NICE’s costing report.
Back to algorithm
9
Build an action plan
If your organisation is not meeting the recommendations, the NICE manager
and clinical lead should work together to develop an action plan. The details of
your action plan will depend on the results of your baseline assessment and
your local circumstances.
In consultation with a range of experts in dermatology we have identified three
key areas to help implementation:
 educate healthcare professionals
 inform and support children and families
 schools and childcare.
Suggested actions
Educate healthcare professionals
Identifying and managing atopic eczema and trigger factors is key to
improving the quality of life of the child. It is important that the professionals
involved in the child's health, in particular primary care professionals and
community pharmacists, are able to identify the condition and know how best
to treat it, especially the continuous use of emollients.
 Education should be available for primary care healthcare professionals on
assessing and diagnosing atopic eczema in children, potential trigger
factors and the stepped-care approach to management. Consider providing
information packs (which could include the quick reference guide) or
posters containing the relevant information.
 Education could include:
 diagnosing atopic eczema in children with dark skin as it may present
differently
 appropriate management using emollients and topical corticosteroids
 use and application of emollients
 when it is appropriate to refer to specialist services.
10
 Obtain information on allergies from Allergy UK or National Eczema
Society.
Inform and support children and families
Children and families need to be provided with information about the condition
and treatments, including benefits and risks. They should also have support to
enable them to manage the condition and potential trigger factors. There is an
‘Understanding NICE guidance’ booklet for parents and carers of children with
atopic eczema.
 Use the stepped-care table in the quick reference guide to explain to
children and families how the condition is managed.
 Information should cover how to manage the condition, use of emollients,
infections, trigger factors and the management of flares. The National
Eczema Society produces fact sheets about eczema and allergies which
can be given to families.
 It may help to show parents/carers photos of infected atopic eczema to
help them recognise it. Photos can be obtained from online databases or
from local dermatology services.
 Consider providing information and practical demonstrations in a group
setting, for example in nurseries, schools and after school clubs, as well as
clinical settings such as GP appointments or dermatology clinics.
 Community pharmacists should have enough information to enable them to
advise children and their parents/carers about atopic eczema and its
treatments, especially the appropriate use of emollients and topical
corticosteroids.
Schools and childcare
For children up to the age of 12 years, schools and childcare play a significant
role in helping manage the condition and empowering children to manage it
themselves.
11
 Healthcare professionals could provide information or training for school
staff about atopic eczema, including the importance of access to
emollients.
 School health teams may want to use the healthcare plan (from ‘Managing
medicines in schools and early years settings’, available from
www.dh.gov.uk/) to help children with atopic eczema manage their
condition at school.
 Childminders should contact their local training provider for training on the
management of eczema.
 Schools can obtain activity packs about eczema from the National Eczema
Society.
Back to algorithm
12
National support for local action* [Back to build an action plan]
Document
Relevance
Managing medicines in schools and
early years settings
Department for Education and
Skills/Department of Health (2005)
 Designed to help schools and early years settings and their employers develop effective management systems
to support individual children with medical needs who require access to their medicines whilst in school.
National service framework for
children, young people and maternity
services: medicines and young people
Department of Health (2004)
 This is the standard on medicines which forms part of the National service framework for children, young people
and maternity services. It refers to NHS, home, educational, childcare and early years settings.
Sources of further information* [Back to build an action plan]
Document
Relevance
National Eczema Society
 Contains information, fact sheets and information about local groups.
Allergy UK
 Has information on allergy and eczema, including patient leaflets.
British Association of Dermatologists
 Includes patient leaflets.
British Dermatological Nursing Group
 Useful for training, events and publications in dermatology.
Primary Care Dermatology Society
 Lists courses for doctors, nurses and pharmacists in dermatology.

NICE Evidence Search
 Links to research and guidance for all types of skin conditions.
British Skin Foundation
 Provides information on eczema, treatments (and those that are not recommended) and allergies.
NHS Choices
 Contains information on symptoms, diagnosis and treatment.
BMJ Learning

Two e-learning modules: Eczema – a guide to management, and, Management of difficult and severe
eczema in childhood.
There is a charge to access these modules.
13
*Please note that the Institute is not responsible for the quality or accuracy of any information or advice provided by any other
organisation.
Related NICE guidance [Back to build an action plan]
Document
Relevance
NICE Quality Standard on Atopic
Eczema in Children
Frequency of application of topical
corticosteroids for atopic eczema
NICE technology appraisal 81 (2004)
 A concise set of prioritised statements designed to drive measurable quality improvements.
Tacrolimus and pimecrolimus for atopic
eczema. NICE technology appraisal 82
(2004)
 Guidance on appropriate prescribing and use of tacrolimus and pimecrolimus for atopic eczema in adults and
children.
 Guidance on the frequency of application of topical corticosteroids for atopic eczema.
Back to algorithm
14
Disseminate and implement plan
Once the action plan and assessment of cost have been approved by the
NICE manager the work of implementing the action plan begins. To ensure
effective implementation all relevant organisations should sign up to the action
plan – for example, via a local area agreement.
Back to algorithm
15
Review and monitor
Implementation of the guideline should be reviewed and monitored, with
results fed back to the relevant trust board.
One way to monitor implementation of the guideline is to audit current practice
against the NICE guidance. The guideline is accompanied by audit support to
help you with this.
Implementation and uptake of NICE guidance
The ERNIE (evaluation and review of NICE implementation evidence)
database is a source of information on the implementation and uptake of
NICE guidance.
ERNIE will provide:
 a bank of guidance-specific NICE implementation uptake reports
 references to external literature
 a simple classification system summarising the uptake of NICE guidance.
Back to algorithm
16
Share learning
Have you got some tips to share with other organisations on implementing
NICE clinical or public health guidance? Or would you like to learn from other
people’s experiences? If so, the Institute’s ‘shared learning’ database can
help.
Back to algorithm
17
Acknowledgements
Thank you to everyone who has contributed to the development of this advice,
including participants in the implementation planning meeting:
 Sue Lewis-Jones, Guideline Development Group Chair, Ninewells Hospital
& Medical School.
 Christine Clark, Independent Medical Writer/Research Fellow, University of
Bradford.
 Jean Robinson, Barts and the London NHS Trust.
 Amanda Roberts, DAX Products.
 Gill Devereaux, Community Practitioners & Health Visitors Association.
 Mr Stephen Tomlin, Neonatal and Paediatric Pharmacists Group/Royal
Pharmaceutical Society of Great Britain.
 Tracey Thompson, British Dermatological Nursing Group.
 Val Sumner, NHS Direct.
 Joan Myers, Royal College of Nursing.
 Rosemary Turnbull, Royal College of Nursing.
 Shailen Rao, Primary Care Pharmacists Association.
 Dr Elizabeth Ogden, Primary Care Dermatology Society.
 Dr Nigel Burrows, British Society for Dermatology.
 Margaret Cox, National Eczema Society.
Thank you also to members of the National Collaborating Centre for Women
and Children's Health and the Guideline Development Group (see appendix A
in the NICE guideline).
18
Thank you to the following members of the NICE Implementation External
Reference Group, and the people who were consulted through telephone
interviews and meetings:
 Allan Melzack, Pharmacist, Tesco
 Elizabeth Higgins, Consultant Dermatologist, King’s College Hospital
 Pauline Reid-Corr, Childminder, Waltham Forest
 Helen Ross, Mid Essex PCT/School and Public Health Nurses Association
 Rita Ramal, Clinical Effectiveness Coordinator, Royal College of
Paediatrics and Child Health
 Margaret Medler, General Manager Clinical Governance, Basildon &
Thurrock University Hospital NHS Foundation Trust
 Jennifer Knight, Clinical Effectiveness Facilitator, Berks Health Care NHS
Foundation Trust.
Back to algorithm
19