What is the recommended treatment for nummular eczema?

From the Guidelines

The recommended treatment for nummular eczema includes topical corticosteroids as first-line therapy, typically starting with medium-potency options like triamcinolone 0.1% ointment applied twice daily to affected areas for 2-3 weeks, as supported by the most recent guidelines 1. For severe or resistant cases, high-potency corticosteroids like clobetasol 0.05% may be needed for short periods (1-2 weeks). Moisturizing is essential and should be done multiple times daily with fragrance-free emollients like petroleum jelly or ceramide-containing creams to repair the skin barrier, as emphasized in the management of atopic eczema 1. Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) can be used for sensitive areas or as steroid-sparing agents, considering their effectiveness in acute and maintenance therapy of atopic dermatitis 1. Oral antihistamines such as cetirizine 10mg daily or hydroxyzine 25mg at bedtime help control itching. For infected lesions, topical antibiotics like mupirocin or oral antibiotics such as cephalexin 500mg four times daily for 7-10 days may be necessary, taking into account the recommendations for systemic antibiotics in patients with evidence of infection 1. Wet wrap therapy can provide relief for severe flares by applying moisturizer, covering with damp gauze, then a dry layer for 2-8 hours. These treatments work by reducing inflammation, repairing the skin barrier, and addressing the characteristic coin-shaped, intensely itchy lesions of nummular eczema. Avoiding triggers like harsh soaps, hot water, and irritating fabrics is also important for management, as suggested by the expert panel of the international eczema council 1. Phototherapy, particularly narrowband ultraviolet B (NB-UVB), may be considered for recalcitrant cases or after failure of first-line treatment with topical agents, based on its efficacy for moderate-to-severe atopic dermatitis 1.

Some key considerations in the treatment of nummular eczema include:

• The use of topical corticosteroids with caution, especially in thinned-skin areas, and the potential for undertreatment due to "steroid phobia" 1.
• The importance of moisturizing to repair the skin barrier and reduce the need for topical corticosteroids 1.
• The role of topical calcineurin inhibitors as effective, steroid-sparing agents for acute and maintenance therapy 1.
• The need for careful consideration of systemic therapy, including antibiotics and immunosuppressants, in patients with severe or resistant disease, as outlined by the international eczema council 1.

Overall, the treatment of nummular eczema should be tailored to the individual patient's needs, taking into account the severity of the disease, the presence of any triggers or allergies, and the potential risks and benefits of different treatment options, as guided by the most recent and highest quality evidence 1.

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.Occlusive dressing may be used for the management of psoriasis or recalcitrant conditions.If an infection develops, the use of occlusive dressing should be discontinued and appropriate antimicrobial therapy instituted. The recommended treatment for nummular eczema is topical corticosteroids, such as triamcinolone acetonide, applied to the affected area as a thin film two to three times daily depending on the severity of the condition 2.

• Key points:
  • Apply a thin film to the affected area
  • Frequency: two to three times daily
  • Severity of the condition determines frequency of application
  • Occlusive dressing may be used for recalcitrant conditions, but infection requires discontinuation of occlusive dressing and antimicrobial therapy.

From the Research

Nummular Eczema Treatment

• Nummular eczema, also known as discoid eczema, is a type of eczema that presents as coin-shaped patches of dry, itchy skin 3.
• The treatment for nummular eczema typically involves topical corticosteroids, which are considered first-line therapy for most cases of eczema 3, 4.
• Topical corticosteroids can be classified into different potencies, with stronger potencies being more effective for moderate to severe eczema 4.
• The use of potent topical corticosteroids has been shown to be effective in achieving treatment success, defined as cleared or marked improvement on the Investigator Global Assessment (IGA) of clinician-reported signs of eczema 4.
• Applying potent topical corticosteroids once a day probably does not decrease the number achieving treatment success compared to twice daily application 4.
• Topical immunomodulators, such as tacrolimus and pimecrolimus, can also be used to treat nummular eczema, especially for patients with mild to moderate disease 5.
• These topical immunomodulators have been shown to be effective in reducing inflammation and improving symptoms, without the risk of skin atrophy associated with long-term use of topical corticosteroids 5.
• The long-term safety of topical corticosteroids in atopic dermatitis has been evaluated in several studies, with evidence suggesting that intermittent use of topical corticosteroids probably results in little to no difference in risk of growth abnormalities, non-skin infections, impaired vaccine response, and lymphoma/non-lymphoma malignancies 6.

Treatment Options

• Topical corticosteroids:
  • Mild potency: for mild eczema
  • Moderate potency: for moderate eczema
  • Potent potency: for severe eczema
• Topical immunomodulators:
  • Tacrolimus
  • Pimecrolimus
• Other treatments:
  • Emollients to enhance the barrier function of skin
  • Phototherapy for moderate to severe cases
  • Systemic therapy for severe cases that do not respond to topical treatment

Important Considerations

• The choice of treatment should be individualized based on the severity of the disease, the patient's medical history, and the presence of any comorbidities.
• Patients should be educated on the proper use of topical corticosteroids and the potential risks associated with long-term use.
• Regular follow-up appointments with a healthcare provider are necessary to monitor the patient's response to treatment and adjust the treatment plan as needed.