Recommendations for referral to secondary care, from the guidelines for the management of atopic eczema from the Primary Care Dermatology Society and British Association of Dermatologists1
It is important to refer patents if a diagnosis is, or has become, uncertain
Urgent referral and prompt antiviral treatment if severe infection with herpes simplex (eczema herpeticum) is suspected
Refer if the eczema is severe and has not responded to appropriate therapy in primary care, particularly if excessive amounts of potent topical corticosteroids are being prescribed (or moderately potent corticosteroids in children)
Refer if the eczema becomes infected with bacteria (manifest as weeping, crusting or the development of pustules) and treatment with an oral antibiotic plus a topical corticosteroid has failed
Refer if the eczema is giving rise to severe social or psychological problems; prompts to referral should include sleeplessness and school absenteeism
Refer if management in primary care has not controlled the eczema satisfactorily – failure to improve is probably best based upon a subjective assessment by the child or parent
The patient or family might benefit from additional advice on application of treatments (e.g. bandaging techniques)
Refer if contact dermatitis is suspected and confirmation requires patch-testing
Refer if dietary factors are suspected and dietary control is a possibility (rare)
The referral letter should include the reason for referral, what it is hoped will be gained from the referral, and what treatments have been tried so far