From the Guidelines
Management of an acute flare of eczema in adults should prioritize the use of topical corticosteroids, emollients, and avoidance of triggers, with consideration of phototherapy or systemic therapies for severe or refractory cases, as recommended by the 2024 guidelines from the American Academy of Dermatology 1.
Key Considerations
- Identify and remove triggers causing the flare, such as irritants, allergens, or stress
- Apply potent topical corticosteroids like betamethasone valerate 0.1% or fluocinonide 0.05% cream twice daily for 7-14 days to reduce inflammation and itching
- Use emollients like petroleum jelly or ceramide-containing moisturizers at least 2-3 times daily to repair the skin barrier
- Consider phototherapy, such as ultraviolet B or ultraviolet A1, for severe or widespread cases
- Systemic therapies, including injectable monoclonal antibodies (biologics) like dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib, may be considered for refractory cases
Treatment Approach
- For mild to moderate flares, topical corticosteroids and emollients may be sufficient
- For severe flares, consider adding phototherapy or systemic therapies
- For flares unresponsive to these measures, consider oral corticosteroids like prednisone (starting at 40mg daily with a 2-week taper), though this should be used sparingly due to rebound effects
Important Notes
- The decision to initiate 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
- The evidence review identified significant gaps in our current understanding of various systemic therapies for eczema, and more randomized controlled trial evidence is needed to better understand the role of phototherapy in the treatment of eczema 1
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Management of Acute Flare of Eczema in Adults
Treatment Options
- Topical corticosteroids are the first-line treatment for atopic dermatitis flare-ups 2, 3
- Topical calcineurin inhibitors, such as pimecrolimus and tacrolimus, can be used in conjunction with topical corticosteroids as first-line treatment 2, 3
- Proactive therapy with twice weekly use of both topical corticosteroids and calcineurin inhibitors in previously affected areas has been found to reduce the time to the next eczematous flare 2
- Adjunctive treatment options include wet wrap therapy, anti-histamines, and vitamin D supplementation 2
- Systemic antibiotics may be warranted in cases of infected lesions, but empiric antibiotics use in uninfected lesions is controversial 2
Prevention of Flares
- Maintenance therapy consists of liberal use of emollients and daily bathing with soap-free cleansers 3
- Use of topical corticosteroids and calcineurin inhibitors can help prevent flares 2, 3
- Avoiding triggers such as irritants, allergens, and stress can also help prevent flares 4, 5
Newer Treatments
- Newer medications approved by the U.S Food and Drug Administration, such as crisaborole and dupilumab, are effective in treating atopic dermatitis but are currently cost prohibitive for most patients 3
- Biological agents have been investigated with promising results 2
- Janus kinase (JAK) inhibitors and phosphodiesterase-4 (PDE-4) inhibitors are also being studied as potential treatments for atopic dermatitis 6
Treatment of Difficult-to-Treat AD
- Difficult-to-treat AD may require re-evaluation of the initial diagnosis of AD, especially if the onset of disease occurs in adulthood 2
- Evaluation for contact, food, and inhaled allergens that may exacerbate the underlying AD may be necessary 2
- Systemic therapies, such as oral corticosteroids and immunosuppressants, may be necessary for severe cases 2, 5