What are the treatment options for managing eczema?

Management of Eczema

Topical corticosteroids are the mainstay of treatment for eczema and should be used as first-line therapy, with the least potent preparation required to control symptoms, supplemented by emollients, avoidance of triggers, and appropriate treatment of secondary infections. 1

First-Line Treatment Approach

Avoidance of Triggers

• Avoid soaps and detergents that remove natural skin lipids
• Use dispersible creams as soap substitutes
• Avoid extremes of temperature
• Keep nails short to prevent scratching damage
• Wear cotton clothing instead of irritant materials like wool 1

Bathing and Emollients

• Regular bathing helps with cleansing and hydrating the skin
• Apply emollients after bathing when they are most effective
• Emollients provide a surface lipid film that reduces water loss from the epidermis 1

Topical Corticosteroids

Topical corticosteroids form the cornerstone of eczema management:

1. Potency selection:

   • Use the least potent preparation required to control symptoms
   • Very potent and potent preparations should be used with caution and for limited periods
   • For mild-moderate eczema, mild to moderate potency is often sufficient 1

2. Application guidelines:

   • Apply once or twice daily (once daily is often sufficient)
   • Some newer preparations require only once-daily application
   • Avoid long-term continuous use, especially on sensitive areas 1, 2

3. Common pitfall: Fear of topical steroids often leads to undertreatment. Patient education about proper use and safety is essential to ensure adequate treatment. 1

Secondary Treatment Options

Topical Calcineurin Inhibitors (TCIs)

• Tacrolimus 0.1% is among the most effective treatments, comparable to potent topical steroids 3, 4
• Particularly useful for sensitive sites (face, neck, genital areas) 2
• Pimecrolimus is also effective but should be used with caution
• Important safety note: Should be avoided on malignant or pre-malignant skin conditions 5

Tar Preparations

• Ichthammol (1% in zinc ointment) is less irritant than coal tar
• Useful for lichenified eczema, especially when applied as paste bandages
• Coal tar solution (1%) is generally preferred to crude coal tar 1

Antihistamines

• Primarily useful for their sedative properties during severe pruritic flares
• Should be used as short-term adjuvant to topical treatment
• Non-sedating antihistamines have little value in eczema management
• May develop tachyphylaxis with prolonged use 1, 2

Management of Complications

Infection Management

1. Bacterial infections:

   • Flucloxacillin is first-line for Staphylococcus aureus (most common pathogen)
   • Phenoxymethylpenicillin for β-hemolytic streptococci
   • Erythromycin for penicillin-allergic patients or resistant cases 1

2. Viral infections:

   • Eczema herpeticum requires prompt treatment with oral acyclovir
   • Use intravenous acyclovir for ill, febrile patients 1

Advanced Therapies for Refractory Cases

Newer Topical Options

• JAK inhibitors (ruxolitinib 1.5%, delgocitinib 0.5%) rank among the most effective treatments in recent studies 3, 4
• PDE-4 inhibitors (crisaborole, roflumilast) are available but generally less effective than potent TCS or TCIs 3, 4

Systemic Therapy

• Reserved for severe, refractory cases after failure of topical treatments
• Systemic corticosteroids have a limited but definite role in severe cases
• Should not be used for maintenance treatment 1

Monitoring and Safety Considerations

Local Adverse Effects

• Application site reactions: Most common with tacrolimus 0.1% and crisaborole 2%, least common with topical steroids 3, 4
• Skin thinning: No evidence of increased risk with short-term TCS use, but may occur with longer-term use (6-60 months) 3, 4
• Pituitary-adrenal suppression: Risk increases with potent/very potent steroids, especially with occlusion or extensive use 1

Special Populations

• Children: Use lower potency steroids when possible
• Sensitive areas: Use mild steroids or TCIs on face, neck, and genital areas
• Immunocompromised patients: Safety and efficacy of some treatments like pimecrolimus have not been established 5

Treatment Algorithm

1. Mild eczema:

   • Daily emollients
   • Mild topical corticosteroids for flares
   • Avoidance of triggers

2. Moderate eczema:

   • Daily emollients
   • Moderate potency topical corticosteroids for body
   • TCIs or mild steroids for face/sensitive areas
   • Consider antihistamines for severe itching

3. Severe eczema:

   • Daily emollients
   • Potent topical corticosteroids for short periods
   • TCIs for maintenance and sensitive areas
   • Consider referral for systemic therapy if inadequate response

Remember that under-treatment is a common problem in eczema management. The "get control then keep control" approach using appropriate potency topical treatments is recommended for optimal outcomes 2.