What are the treatment options for eczema?

Treatment Options for Eczema

Topical corticosteroids are the mainstay of treatment for eczema, with potency selection based on severity, and should be used in conjunction with emollients and other supportive measures to effectively manage the condition. 1

First-Line Treatment Approach

Skin Care and Emollients

• Avoid irritants: Soaps, detergents, and woolen clothing should be avoided as they can exacerbate eczema 1
• Use cotton clothing instead of wool which is more comfortable for eczema patients 1
• Bathing is beneficial for both cleansing and hydrating the skin
• Emollients should be applied after bathing to provide a surface lipid film that retards water loss from the epidermis 1
• The order of application between emollients and topical corticosteroids does not significantly affect treatment outcomes 2

Topical Corticosteroids

Topical corticosteroids remain the cornerstone of eczema treatment with the following guidelines:

• Potency selection:

  • Mild eczema: Mild potency corticosteroids
  • Moderate eczema: Moderate potency corticosteroids
  • Severe eczema: Potent corticosteroids for limited periods 1

• Application frequency:

  • Once daily application of potent corticosteroids is as effective as twice daily application 3
  • Treatment should not be applied more than twice daily 1

• Duration of use:

  • Use the least potent preparation required to control eczema
  • When possible, corticosteroids should be stopped for short periods 1
  • Short bursts (3 days) of potent corticosteroids can be as effective as prolonged use (7 days) of mild preparations for children with mild to moderate eczema 4

Managing Infections

• Antibiotics are important for treating secondary bacterial infections 1
• Flucloxacillin is the first choice for Staphylococcus aureus (most common pathogen)
• Phenoxymethylpenicillin for β-hemolytic streptococci
• Erythromycin for penicillin-allergic patients or resistant cases 1
• Eczema herpeticum (herpes simplex infection) requires oral acyclovir early in the course of disease, or intravenous acyclovir for ill, feverish patients 1

Second-Line Treatment Options

Topical Calcineurin Inhibitors

• Pimecrolimus cream 1% (Elidel) is FDA-approved for short-term and intermittent treatment of mild to moderate eczema in patients ≥2 years old who have failed other treatments 5
• Key considerations for pimecrolimus:
  • Not for continuous long-term use due to potential cancer risk concerns
  • Should only be used on areas with eczema
  • Not for children under 2 years old 5
  • Less effective than moderate and potent corticosteroids 6
  • May be particularly useful for treating facial eczema (81% success rate) 7

Antihistamines

• Primarily valuable for their sedative properties
• Useful as short-term adjuvant during severe pruritus flares
• Non-sedating antihistamines have little to no value in eczema
• Should be used at night while asleep; daytime use should be avoided
• Children may require larger doses 1

Tar Preparations

• Ichthammol (less irritating than coal tar) can be applied as:
  • 1% ichthammol in zinc ointment
  • Paste bandages (particularly useful for lichenified eczema)
• Coal tar solution (1%) is generally preferred to crude coal tar 1

Third-Line and Advanced Treatments

Phototherapy

• Option for patients not responding to first and second-line treatments
• Narrow band ultraviolet B (312 nm) is available
• Concerns exist about long-term adverse effects including premature skin aging and cutaneous malignancies 1

Systemic Corticosteroids

• Limited but definite role for severe atopic eczema
• Should never be used lightly
• Not for maintenance treatment until all other options exhausted
• Try to avoid during crises 1

Specialist Referral Criteria

Refer to a specialist when:

• Failure to respond to first-line management
• Diagnostic uncertainty
• Severe or deteriorating eczema
• Recurrent secondary infection 1

Common Pitfalls to Avoid

1. Undertreatment due to steroid phobia: Explain the benefits and risks of topical corticosteroids to patients/parents to improve adherence 1

2. Overuse of potent corticosteroids: While rare (1% incidence in studies), skin thinning can occur, particularly with very potent and potent preparations 3

3. Incorrect diagnosis of infection: Take bacteriological swabs when patients don't respond to treatment 1

4. Ignoring psychological aspects: Consider psychological support, relaxation therapy, or self-hypnosis techniques for patients struggling with eczema 1

5. Continuous use of calcineurin inhibitors: Pimecrolimus should not be used continuously for long periods due to potential cancer risk concerns 5

6. Overlooking dietary factors: Consider dietary manipulation only when history strongly suggests food allergy or when widespread eczema is not responding to first-line treatment 1