What is the recommended management for eczema?

Management of Eczema (Atopic Dermatitis)

Topical corticosteroids are the mainstay of treatment for atopic eczema and should be used aggressively with emollients to gain control, then maintained with proactive therapy to prevent flares 1, 2.

Core Treatment Algorithm

First-Line Management (All Patients)

Emollients and Skin Care:

• Apply emollients liberally and frequently, most effectively after bathing 1, 2
• Use dispersible cream as soap substitute—avoid all soaps and detergents that strip natural skin lipids 1
• Bathe for cleansing and hydration; patients choose their preferred bath oil 1

Topical Corticosteroids:

• Use the least potent preparation needed to control disease 1
• Apply once daily (not twice daily—newer evidence shows once daily is equally effective) 3
• Use potent/very potent steroids cautiously and for limited periods only 1
• Stop for short periods when possible 1
• Address steroid phobia directly—undertreatment is common due to unfounded fears 1, 4

Proactive Maintenance Therapy:

• After gaining control, continue intermittent topical anti-inflammatory treatment on previously affected areas to prevent flares 2, 5
• This "get control then keep control" approach is evidence-based 3

Environmental Modifications

Avoid Irritants:

• Keep nails short 1
• Avoid extremes of temperature 1
• Wear cotton clothing next to skin, not wool 1
• Avoid fragrances, solvents, acids, and bleaches 6

What NOT to do:

• Do NOT use special laundering techniques—insufficient evidence 6
• Do NOT routinely use emollient bath additives—no proven benefit 3
• Do NOT use silk clothing or ion-exchange water softeners—not shown to help 3

Treatment for Active Disease/Flares

Topical Anti-Inflammatory Options (Beyond Corticosteroids)

Calcineurin Inhibitors:

• Useful for sensitive sites (face, eyelids, genitals) 3, 7
• Alternative when corticosteroid concerns exist 2

Newer Topical Agents:

• PDE4 inhibitors (crisaborole) 2
• Topical JAK inhibitors 2, 8

Adjunctive Therapies

For Infection:

• Treat overt bacterial infection with antibiotics 1
• Flucloxacillin for S. aureus (most common pathogen) 1
• Phenoxymethylpenicillin for β-hemolytic streptococci 1
• Erythromycin for penicillin allergy or resistance 1
• Oral acyclovir for eczema herpeticum (IV if febrile/ill) 1, 6
• Dilute bleach baths may be considered 2

What NOT to use:

• Do NOT routinely use oral or topical antistaphylococcal treatments for infected eczema without clear infection 3

For Pruritus:

• Sedating antihistamines only for short-term use at night when sleep is disturbed 1, 6
• Do NOT use non-sedating antihistamines—they have no value in atopic eczema 1, 3
• Do NOT use antihistamines routinely 4, 3

Tar Preparations

• Ichthammol (1% in zinc ointment) or coal tar solution (1%) for lichenified eczema 1
• Paste bandages can be particularly useful 1

Systemic Treatment (Severe/Refractory Disease)

When topical therapy fails despite proper use:

Biologics and Small Molecules:

• Dupilumab, lebrikizumab, nemolizumab, tralokinumab 8
• JAK inhibitors: abrocitinib, baricitinib, upadacitinib 2, 8

Conventional Immunosuppressants:

• Cyclosporine, methotrexate, azathioprine, mycophenolate 2, 8

Phototherapy:

• UV phototherapy (narrow-band UVB preferred over PUVA due to lower malignancy risk) 1, 2

Systemic Corticosteroids:

• Avoid if possible—reserved only for acute severe exacerbations as bridge therapy 6
• Never use for maintenance 1, 6
• Risk of pituitary-adrenal suppression and growth interference in children 1

What NOT to Do (Evidence-Based Demotions)

• Do NOT use probiotics—no evidence of benefit 3
• Do NOT apply emollients from birth for prevention—may increase skin infections and food allergy 3, 9
• Do NOT routinely restrict diet in adults; in children, only try in selected infants under professional supervision 1, 2
• Do NOT use vitamin D supplementation routinely (only if documented deficiency) 6

Critical Pitfalls to Avoid

1. Undertreatment due to steroid phobia—address fears directly with education 1, 4
2. Applying topicals twice daily—once daily is sufficient 3
3. Missing secondary infection—look for crusting, weeping, or grouped erosions 1
4. Failing to use proactive maintenance—prevents flares in recurrent disease 5, 3
5. Not providing adequate patient education—demonstrate application technique and provide written information 1

When to Refer to Specialist

• Failure to respond to first-line treatment despite proper adherence 1
• Need for second-line systemic therapies 1
• Suspected contact dermatitis complicating atopic eczema 1
• Severe disease requiring hospitalization 6