What are the treatment options for widespread atopic dermatitis (eczema)?

From the Guidelines

Treatment for widespread eczema should prioritize a multi-faceted approach combining medications, skincare, and trigger avoidance, with a focus on reducing inflammation, repairing the skin barrier, and interrupting the itch-scratch cycle, as recommended by the most recent guidelines 1.

Key Considerations

• For moderate to severe cases, topical corticosteroids like triamcinolone 0.1% or fluocinonide 0.05% should be applied twice daily to affected areas for 1-2 weeks during flares, as supported by older guidelines 1.
• For maintenance, consider less potent options like hydrocortisone 1% or using stronger steroids just 2-3 times weekly.
• Calcineurin inhibitors such as tacrolimus 0.1% or pimecrolimus 1% are effective steroid-free alternatives, especially for sensitive areas like the face.

Systemic Treatments

• For severe widespread eczema, systemic treatments may be necessary, including oral corticosteroids (prednisone 20-40mg daily for 5-7 days), immunosuppressants like cyclosporine (3-5mg/kg/day), or biologics such as dupilumab (initial 600mg dose followed by 300mg every two weeks) 1.
• The decision to initiate these more advanced therapies should be made using shared decision-making between patients and clinicians, taking into account the severity of eczema, its impact on the patient, and the efficacy, safety, and accessibility of the available interventions 1.

Skincare and Trigger Avoidance

• Daily moisturizing is crucial - apply thick, fragrance-free creams or ointments like petroleum jelly or ceramide-containing products immediately after bathing.
• Take short, lukewarm showers using gentle, fragrance-free cleansers.
• Identify and avoid triggers such as certain fabrics, detergents, foods, or environmental allergens.

Recent Guidelines

• The most recent guidelines from the American Academy of Dermatology 1 highlight new evidence that has emerged since the 2014 guidelines, further informing the management of eczema with systemic therapies.
• Strong recommendations are made for the use of biologics such as dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib, while conditional recommendations are made for the use of phototherapy, azathioprine, cyclosporine, methotrexate, and mycophenolate.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Topical corticosteroids are generally applied to the affected area as a thin film from two to three times daily depending on the severity of the condition.

For the treatment of widespread eczema, topical corticosteroids such as triamcinolone acetonide can be applied to the affected area as a thin film, 2-3 times daily, depending on the severity of the condition.

• It is essential to follow the prescribed dosage and administration instructions to minimize the risk of systemic absorption and adverse effects.
• Occlusive dressings may be used for the management of recalcitrant conditions, but their use should be discontinued if an infection develops 2.
• Patients should be evaluated periodically for evidence of HPA axis suppression when using large doses of potent topical steroids applied to large surface areas or under occlusive dressings 2.

From the Research

Treatment Options for Widespread Eczema

• Topical corticosteroids are a first-line treatment for eczema, with potent and moderate topical corticosteroids being more effective than mild topical corticosteroids, primarily in moderate or severe eczema 3
• The effectiveness of topical corticosteroids is similar between once daily and twice daily (or more) frequent use to treat eczema flare-ups 3
• Topical corticosteroids weekend (proactive) therapy is probably better than no topical corticosteroids/reactive use to prevent eczema relapse (flare-ups) 3
• Janus kinase inhibitors, such as ruxolitinib 1.5%, and tacrolimus 0.1% are ranked among the most effective topical anti-inflammatory treatments for eczema 4
• Topical calcineurin inhibitors, such as pimecrolimus and tacrolimus, can be used in conjunction with topical corticosteroids as first-line treatment 5

Management Strategies

• The "get control then keep control" regimen, which involves aggressive use of topical therapies, can help counter under-treatment of eczema 6
• Good patient education and liberal use of emollients are important aspects of eczema management 6, 5
• Maintenance therapy consists of daily bathing with soap-free cleansers and liberal use of emollients 5
• Ultraviolet phototherapy is a safe and effective treatment for moderate to severe atopic dermatitis when first-line treatments are not adequate 5

Safety and Efficacy

• Local adverse events, such as abnormal skin thinning, are not well reported and come largely from low- or very low-certainty, short-term trials 3
• Skin thinning was not increased with short-term use of any topical steroid potency, but was reported in 6/2044 (0.3%) participants treated with longer-term (6-60 months) topical steroids 4
• Local application site reactions were most common with tacrolimus 0.1% and crisaborole 2%, and least common with topical steroids 4