What is the best treatment for a severe eczema flare?

From the Guidelines

For severe eczema flares, the most effective treatment approach is a combination of potent topical corticosteroids, daily moisturizers, and oral antihistamines, as recommended by the Joint Task Force and American Academy of Dermatology guidelines 1.

Treatment Approach

• Start with a potent topical corticosteroid like betamethasone valerate 0.1% or fluocinonide 0.05% applied twice daily to affected areas for 7-14 days.
• Pair this with a daily moisturizer applied liberally across the entire body, ideally within minutes after bathing.
• For intense itching, an oral antihistamine such as cetirizine 10mg daily or hydroxyzine 25mg at bedtime can provide relief.

Additional Therapies

• If the flare is extensive or not responding to topical treatments, a short course of oral prednisone may be necessary (typically 40mg daily, tapered over 2 weeks) 1.
• Wet wrap therapy can also help - apply medication, cover with damp cotton clothing, then a dry layer overtop for 2-8 hours.
• Avoid triggers like harsh soaps, fragrances, and known allergens.

Phototherapy

• Phototherapy, such as narrow-band UVB, can be considered for recalcitrant AD or after failure of first-line treatment with topical agents 1.
• However, the evidence for phototherapy in severe eczema flares is not as strong as for topical corticosteroids and moisturizers.

Systemic Treatments

• Systemic immunosuppressants, such as cyclosporine, azathioprine, and methotrexate, can be considered for severe AD refractory to topical treatments and phototherapy 1.
• However, these treatments should be used with caution and under close medical supervision due to potential side effects.

From the FDA Drug Label

ELIDEL Cream is a prescription medicine used on the skin (topical) to treat eczema (atopic dermatitis). ELIDEL Cream is for adults and children age 2 years and older who do not have a weakened immune system. ELIDEL Cream is used on the skin for short periods, and if needed, treatment may be repeated with breaks in between.

The best treatment for a severe eczema flare is not explicitly stated in the provided drug labels. However, pimecrolimus (ELIDEL) Cream 1% is a prescription medicine used to treat eczema (atopic dermatitis) in adults and children age 2 years and older who do not have a weakened immune system.

• It is used on the skin for short periods, and if needed, treatment may be repeated with breaks in between.
• Patients should use the smallest amount of ELIDEL Cream needed to control the signs and symptoms of eczema.
• Treatment should be stopped when the signs and symptoms of eczema go away, or as directed by the doctor 2.
• It is essential to follow the doctor's advice if symptoms of eczema return after a treatment with ELIDEL Cream 2.

From the Research

Treatment Options for Severe Eczema Flare

• Topical corticosteroids are a common treatment for eczema, with stronger potencies being more effective for moderate to severe eczema 3
• A study comparing once-daily and twice-daily application of fluticasone propionate 0.05% cream found no significant difference in clinical response between the two groups 4
• Cyclosporin has been shown to be more efficacious than prednisolone for severe adult eczema, with a higher proportion of patients achieving stable remission 5
• Narrow-band ultraviolet B (UVB) phototherapy has been found to be an effective adjunctive treatment for moderate to severe atopic eczema, with a significant reduction in total disease activity and extent of disease 6
• Long-term follow-up of eczema patients treated with cyclosporine has shown that long-term remissions are possible, even with a relatively short treatment period 7

Comparison of Treatment Options

• A comparison of potent and moderate topical corticosteroids found that they are probably more effective than mild topical corticosteroids for moderate or severe eczema 3
• There is uncertain evidence to support any advantage of very potent over potent topical corticosteroids 3
• Cyclosporin has been shown to be more efficacious than prednisolone for severe adult eczema 5

Safety and Efficacy

• Local adverse events, such as abnormal skin thinning, were found to be low overall, but increased with increasing potency of topical corticosteroids 3
• Narrow-band UVB phototherapy was found to be well tolerated by most patients, with a small proportion developing erythema or experiencing a flare in their eczema 6
• Cyclosporine has been shown to be effective in the long-term treatment of eczema, with a significant reduction in disease activity and a high proportion of patients remaining in remission 7