What are the treatment options for eczema?

Treatment Options for Eczema

Topical corticosteroids are the mainstay of treatment for eczema and should be used with appropriate potency based on severity, with emollients as essential complementary therapy. 1

First-Line Treatment Approach

Avoidance of Triggering Factors

• Avoid soaps and detergents that remove natural skin lipids
• Use dispersible creams as soap substitutes
• Avoid extreme temperatures
• Keep nails short to minimize damage from scratching
• Wear cotton clothing instead of wool or synthetic irritants 1

Bathing and Emollients

• Regular bathing helps cleanse and hydrate the skin
• Apply emollients after bathing for maximum effectiveness
• Emollients create a protective lipid film that prevents water loss from the epidermis 1

Topical Corticosteroids

Topical corticosteroids should be prescribed according to a stepwise approach:

1. Mild eczema: Use mild potency (e.g., hydrocortisone 1%)
2. Moderate eczema: Use moderate potency (e.g., clobetasone butyrate 0.05%)
3. Severe eczema: Use potent preparations for limited periods 1, 2

Application Guidelines:

• Apply once or twice daily (once daily is equally effective for potent corticosteroids) 2
• Use the least potent preparation required to control symptoms
• Include short breaks from corticosteroids when possible
• Very potent and potent categories should be used with caution for limited periods only 1

Important: Many patients have unwarranted fears about topical corticosteroids. Studies show 72.5% of patients worry about using them, with 24% admitting non-compliance due to these concerns. Patient education about proper use is essential. 3

Managing Secondary Infection

• Antibiotics are important for treating secondary bacterial infection
• Flucloxacillin is usually most appropriate for Staphylococcus aureus (most common pathogen)
• Phenoxymethylpenicillin for β-hemolytic streptococci
• Erythromycin for penicillin-allergic patients or resistant cases 1

Second-Line Treatment Options

Calcineurin Inhibitors

Pimecrolimus cream 1% (Elidel) is indicated for:

• Patients aged 2 years and older
• Short-term treatment with breaks between courses
• Use after other prescription medicines have failed
• Not for continuous long-term use 4

Safety Considerations:

• Not for use in children under 2 years
• Not for patients with weakened immune systems
• Avoid sun exposure during treatment
• Do not cover treated areas with bandages or wraps 4

Tar Preparations

• Ichthammol (less irritant than coal tar) can be applied as 1% ointment or paste bandages
• Particularly useful for lichenified eczema
• Coal tar solution (1%) can be used with hydrocortisone ointment 1

Antihistamines

• Primarily valuable for their sedative properties
• Useful as short-term adjuvant during severe pruritus episodes
• Non-sedating antihistamines have little value in eczema
• May require larger doses in children
• Effectiveness may decrease over time due to tachyphylaxis 1

Proactive Treatment Strategy

Weekend (proactive) therapy with topical corticosteroids significantly reduces relapse rates:

• Applying topical corticosteroids twice weekly after clearing of active lesions
• Reduces likelihood of relapse from 58% to 25%
• Recommended for maintenance after achieving control 2

Special Considerations

Order of Application

The order of application between emollients and topical corticosteroids does not significantly affect treatment outcomes. Parents can apply medications in whichever order they prefer, with a 15-minute interval between applications. 5

Short Bursts vs. Prolonged Use

A short burst (3 days) of a potent topical corticosteroid followed by base ointment is just as effective as prolonged use (7 days) of a mild preparation for controlling mild to moderate atopic eczema in children. 6

When to Refer to a Specialist

Refer to a dermatologist when:

• Failure to respond to first-line treatments
• Uncertain diagnosis
• Widespread severe eczema
• Recurrent secondary infection
• Significant impact on quality of life 1

Safety and Adverse Events

• Abnormal skin thinning is rare (approximately 1% in clinical trials)
• Risk increases with higher potency corticosteroids
• Short-term application of moderate potency corticosteroids like clobetasone butyrate 0.05% shows no clinically significant difference in skin thinning potential compared to hydrocortisone 1% 7
• Systemic absorption is minimal with appropriate use 1, 7