What are the recommended topical treatments for eczema?

Recommended Topical Treatments for Eczema

Topical corticosteroids are the mainstay of treatment for atopic eczema and should be used with emollients as first-line therapy, with the least potent preparation required to control symptoms. 1

First-Line Treatments

Emollients

• Apply liberally and frequently, especially after bathing
• Most effective when applied to slightly damp skin after bathing
• Provide a surface lipid film that reduces water loss from the epidermis
• Should be used as soap substitutes to cleanse the skin instead of regular soaps/detergents
• Can be used in conjunction with other topical treatments

Topical Corticosteroids

Topical corticosteroids should be used according to a stepwise approach:

1. Potency selection:

   • Mild eczema: Mild potency (e.g., 1% hydrocortisone)
   • Moderate eczema: Moderate potency
   • Severe eczema: Potent preparations
   • Very potent preparations should be used with caution and for limited periods only

2. Application frequency:

   • Once daily application of potent corticosteroids is as effective as twice daily application 2
   • Treatment should not be applied more than twice daily 1
   • Some newer preparations require only once daily application

3. Duration of use:

   • Use for short periods to control flares
   • When possible, corticosteroids should be stopped for short periods
   • For maintenance, consider weekend therapy (proactive approach) to prevent relapses 2

Important: The basic principle is to use the least potent preparation required to keep the eczema under control 1

Second-Line Treatments

Topical Calcineurin Inhibitors (TCIs)

• Pimecrolimus (Elidel) cream 1% for mild to moderate eczema
• Important safety considerations for pimecrolimus: 3
  • Not for continuous long-term use
  • Not for use in children under 2 years old
  • Should be used only after other prescription medicines have failed
  • Apply a thin layer to affected areas only

Tar Preparations

• Ichthammol and coal tar can be effective for lichenified eczema
• Ichthammol (1% in zinc ointment) is less irritant than coal tar
• Coal tar solution (1% in hydrocortisone ointment) is generally preferred to crude coal tar
• Particularly useful for healing lichenified eczema when used as paste bandages 1

Adjunctive Treatments

Antihistamines

• Primarily valuable for their sedative properties during severe pruritus
• Non-sedating antihistamines have little to no value in atopic eczema
• Should be used short-term during relapses with severe itching
• May develop tachyphylaxis (reduced effectiveness over time) 1

Antibiotics for Secondary Infection

• For overt bacterial infection (crusting, weeping)
• Flucloxacillin is usually most appropriate for Staphylococcus aureus
• Phenoxymethylpenicillin for β-hemolytic streptococci
• Erythromycin for penicillin allergies or resistance 1

Practical Application Tips

1. Order of application:

   • The order of application of emollients and topical corticosteroids does not significantly affect treatment outcomes 4
   • Allow 15 minutes between applications of different products

2. Addressing corticosteroid phobia:

   • Educate patients about appropriate use and safety of topical corticosteroids
   • 72.5% of patients worry about using topical corticosteroids, which can affect compliance 5
   • Reassure that skin thinning is rare with appropriate use (only 1% of cases in studies) 2

3. Monitoring for adverse effects:

   • Watch for signs of skin thinning, which is more common with higher potency corticosteroids
   • Long-term studies (up to 5 years) show little to no difference in skin thinning when mild/moderate potency corticosteroids are used intermittently 6

Common Pitfalls to Avoid

1. Undertreatment due to steroid phobia:

   • Many patients are undertreated due to fears about topical corticosteroids
   • Educate patients about proper use and safety profile

2. Overuse of potent preparations:

   • Using very potent corticosteroids when not necessary increases risk of side effects
   • Evidence suggests potent corticosteroids may not provide additional benefit over moderate potency in many cases 2

3. Ignoring skin infections:

   • Secondary bacterial or viral infections can worsen eczema
   • Look for crusting, weeping, or grouped punched-out erosions (suggesting herpes simplex)

4. Neglecting provoking factors:

   • Avoid irritants like wool clothing and extreme temperatures
   • Recommend cotton clothing instead of wool 1

5. Inappropriate bathing practices:

   • Avoid hot water and harsh soaps
   • Use bath oils and emollient soap substitutes 1

By following these evidence-based recommendations and avoiding common pitfalls, most patients with eczema can achieve good control of their symptoms with topical treatments.