What are the first line treatments for eczema?

First-Line Treatments for Eczema

Topical corticosteroids are the mainstay of first-line treatment for eczema, used alongside emollients and avoidance of triggering factors. 1

Treatment Algorithm for Eczema

Step 1: Basic Therapy

• Emollients/Moisturizers

  • Apply after bathing for maximum effectiveness 1
  • Use as soap substitutes to cleanse skin (dispersible creams) 1
  • Apply regularly throughout the day

• Avoid Triggering Factors

  • Eliminate soaps and detergents that remove natural skin lipids 1
  • Avoid extremes of temperature 1
  • Keep nails short to minimize damage from scratching 1
  • Wear cotton clothing rather than irritating materials like wool 1

Step 2: Anti-inflammatory Treatment for Active Eczema

• Topical Corticosteroids

  • Use the least potent preparation required to control symptoms 1
  • Application frequency:
    • Apply no more than twice daily 1
    • For potent preparations, once daily application is likely as effective as twice daily 2
    • For adults and children over 2 years: apply to affected areas no more than 3-4 times daily 3
  • Potency selection:
    • Mild to moderate eczema: mild to moderate potency (e.g., 1% hydrocortisone) 1, 4
    • More severe cases: potent preparations may be necessary 2
    • Moderate and potent corticosteroids are probably more effective than mild ones for moderate/severe eczema 2

• Treatment Duration

  • Use for short periods during flares 1
  • Consider weekend therapy (proactive approach) to prevent relapses in recurrent cases 2

Step 3: Managing Common Complications

• For Secondary Bacterial Infection

  • Antibiotics when clinically indicated (crusting, weeping) 1
  • Flucloxacillin is first-line for Staphylococcus aureus (most common pathogen) 1
  • Erythromycin for penicillin-allergic patients 1

• For Herpes Simplex Infection (Eczema Herpeticum)

  • Oral acyclovir early in the course of disease 1
  • Intravenous acyclovir for ill, feverish patients 1

• For Severe Pruritus

  • Sedating antihistamines as short-term adjuvant therapy 1
  • Non-sedating antihistamines have little to no value 1

Important Considerations and Pitfalls

Safety of Topical Corticosteroids

• Skin Thinning Risk

  • Low overall frequency (1% in studies) 2
  • Risk increases with higher potency corticosteroids 2
  • Long-term intermittent use of mild/moderate potency steroids appears safe with minimal skin thinning risk 5

• Systemic Effects

  • Pituitary-adrenal axis suppression is possible but rare with appropriate use 1
  • Growth abnormalities are unlikely with intermittent use in children 5

Common Treatment Errors to Avoid

1. Undertreatment due to steroid phobia

   • Patient fears about steroids often lead to poor adherence 1
   • Education about proper use and safety is essential

2. Overuse of potent preparations

   • Very potent and potent categories should be used with caution for limited periods 1
   • No clear advantage of very potent over potent corticosteroids 2

3. Neglecting emollients

   • Emollients are fundamental to management, not optional 1
   • Most effective when applied after bathing 1

4. Missing secondary infection

   • Deterioration in previously stable eczema may indicate infection 1
   • Look for crusting, weeping (bacterial) or grouped punched-out erosions (viral) 1

When to Refer to a Specialist

• Diagnostic uncertainty
• Failure to respond to first-line treatments
• Need for second-line therapies
• Severe or widespread disease 1

By following this structured approach to eczema management, focusing on emollients, appropriate use of topical corticosteroids, and treating complications promptly, most patients can achieve good disease control with minimal adverse effects.