What are the treatments for eczema?

Treatment for Eczema

The mainstay of treatment for eczema is topical corticosteroids, which should be used at the lowest effective potency to control symptoms, combined with regular emollient therapy to maintain skin barrier function. 1

First-Line Treatment Approach

Emollients and Skin Care

• Use emollients liberally and frequently as the foundation of eczema management
  • Apply after bathing to lock in moisture
  • Use as soap substitutes to avoid drying the skin 1, 2
• Avoid triggers:
  • Replace soaps with dispersible creams
  • Avoid extreme temperatures
  • Wear cotton clothing instead of wool or synthetic fabrics
  • Keep fingernails short to minimize damage from scratching 1

Topical Corticosteroids

• Apply a thin layer to affected areas, typically twice daily 1
• Match potency to severity and location:
  • Mild eczema: Mild potency (1% hydrocortisone)
  • Moderate eczema: Moderate potency
  • Severe eczema: Potent corticosteroids
  • Very severe/resistant: Very potent (e.g., clobetasol propionate) 1, 3
• Important precautions:
  • Limit very potent/potent preparations to short courses (≤2 weeks) 4
  • Do not exceed 50g per week for super-potent formulations like clobetasol 4
  • Avoid occlusive dressings with potent steroids unless specifically indicated 4
  • Monitor for skin thinning with prolonged use 1, 3

Second-Line Treatments

Topical Calcineurin Inhibitors (TCIs)

• Tacrolimus 0.1% and 0.03% are highly effective alternatives to corticosteroids 3, 5
• Particularly useful for:
  • Face and neck areas (less risk of skin thinning)
  • When corticosteroids are ineffective or contraindicated
  • Long-term management 1, 3
• Note: May cause application site reactions (burning/stinging) 3

Topical JAK Inhibitors

• Ruxolitinib 1.5% and delgocitinib 0.5% show high efficacy comparable to potent corticosteroids 3, 5
• Consider when other topicals have failed

Antihistamines

• Primarily useful for sedative properties to help with sleep during flares
• Non-sedating antihistamines have limited value for eczema 1
• May develop tachyphylaxis (reduced effect over time) 1

Management of Complications

Infection

• For bacterial infection (usually Staphylococcus aureus):
  • Flucloxacillin is first choice
  • Erythromycin for penicillin-allergic patients
  • Phenoxymethylpenicillin if β-hemolytic streptococci isolated 1
• For eczema herpeticum (herpes simplex infection):
  • Oral acyclovir early in disease course
  • IV acyclovir for febrile or systemically ill patients 1

Proactive Therapy for Long-Term Control

• After achieving control, consider proactive maintenance:
  • Intermittent, low-dose anti-inflammatory treatment to previously affected areas
  • Continued emollient use on all skin 6
• This approach helps prevent flares rather than just treating them reactively 6

Third-Line Treatments

Phototherapy

• Consider for patients not responding to topical treatments
• Options include narrow-band UVB (312 nm)
• Caution: Long-term risks include premature skin aging and potential malignancies 1

Systemic Treatments

• Reserved for severe, resistant cases after all other options exhausted
• Systemic corticosteroids have a limited role and should not be used for maintenance 1
• Other immunosuppressants (azathioprine, cyclosporine) may be considered in specialist settings 1

When to Refer to a Specialist

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

Common Pitfalls to Avoid

1. Underusing emollients (cornerstone of management)
2. Overusing potent corticosteroids (risk of skin thinning with long-term use)
3. Underusing topical steroids due to unfounded fears (leading to poor control)
4. Failing to address secondary infection promptly
5. Not considering proactive maintenance therapy to prevent flares 1, 6