Atopic eczema flare — SCE Dermatology MCQ

Correct answer: E — Regular emollient and appropriate topical corticosteroid

The correct answer is E, regular emollient and appropriate topical corticosteroid. This presentation, an itchy flexural flare with lichenified excoriated plaques and no fever, vesicles, pustules or honey-coloured crust, is a straightforward uncomplicated flare of atopic eczema precipitated by stopping emollients. NICE CKS recommends a stepped approach in which emollients remain first-line throughout flares and remission, with a topical corticosteroid of appropriate potency added for active inflammation until the skin is clear. Lichenification and excoriation reflect chronic scratching from uncontrolled eczema rather than any secondary pathology, so restoring the standard emollient plus steroid regimen is both necessary and sufficient. There are no clinical features here (systemic upset, vesicles, pustules, crusting) to suggest an alternative diagnosis requiring different treatment. Why the other options are wrong: C. Oral flucloxacillin for presumed infection: there is no honey-coloured crust, pustules, weeping or systemic signs to support bacterial superinfection, so antibiotics are unjustified and would not address the underlying eczema. B. Topical aciclovir to flexural plaques: this targets eczema herpeticum, which presents with punched-out vesicles, erosions and systemic illness, none of which are present here. A. Permethrin cream to the entire body: this treats scabies, which classically causes burrows and widespread intense itch with a different distribution, not a localised flexural eczema flare after emollient cessation. D. Urgent excision biopsy of one plaque: biopsy is reserved for atypical, non-resolving or diagnostically uncertain lesions, not a classic eczema flare with a clear precipitant. Key point: A flexural eczema flare with lichenification and excoriation but no signs of infection or eczema herpeticum should be managed by restarting regular emollients and adding an appropriately potent topical corticosteroid, not antimicrobials, antivirals, scabicides or biopsy.

Reference: NICE CKS, Eczema - atopic, Management, https://cks.nice.org.uk/topics/eczema-atopic/