What are the treatments for eczema?

Treatment Options for Eczema

The mainstay of treatment for eczema is topical corticosteroids of appropriate potency for the affected area, combined with regular emollient use, with calcineurin inhibitors serving as excellent alternatives for sensitive areas or long-term management. 1

First-Line Treatments

Topical Corticosteroids

• Selection based on location and severity:
  • Face/sensitive areas: Use only mild potency (Class 6-7) corticosteroids for short periods (1-2 weeks) 1
  • Body: Use moderate to potent corticosteroids for moderate-severe eczema 2, 3
  • Potent corticosteroids are probably more effective than mild ones for moderate-severe eczema (70% vs 39% treatment success) 3
  • Apply once daily for potent corticosteroids (similar efficacy to twice daily application) 3

Emollients and Moisturizers

• Apply at least twice daily, especially after bathing 1
• Use as soap substitutes for cleansing 2
• Apply after topical medications 1

Calcineurin Inhibitors (TCIs)

• Excellent alternatives for:
  • Facial eczema
  • Sensitive skin areas
  • Long-term management
  • Cases where corticosteroids have failed 1
• Tacrolimus dosing:
  • 0.03% for children ≥2 years
  • 0.1% for adults 1
• Tacrolimus appears more effective than weak corticosteroids, while pimecrolimus may be less effective 4
• Caution: Should not be used on malignant or pre-malignant skin conditions 5

Second-Line Treatments

Anti-histamines

• Primarily valuable for their sedative properties to help with sleep during severe itching 2, 1
• Non-sedating antihistamines have little value in eczema 2
• May develop tachyphylaxis (reduced effect over time) 2

Infection Management

• Treat secondary bacterial infections with appropriate antibiotics:
  • Flucloxacillin for Staphylococcus aureus (most common)
  • Phenoxymethylpenicillin for β-hemolytic streptococci
  • Erythromycin for penicillin allergy 2, 1
• For herpes simplex infection (eczema herpeticum), use oral acyclovir 1

Proactive Therapy for Prevention

• Weekend (twice weekly) application of topical corticosteroids to previously affected areas reduces flare-ups from 58% to 25% 3

Practical Application Tips

Corticosteroid Application

• Apply a thin layer to affected areas only 1
• For potent corticosteroids, once-daily application is as effective as twice-daily 3
• Keep nails short to minimize damage from scratching 2

Avoiding Triggers

• Avoid soaps and detergents that remove natural skin lipids 2
• Wear cotton clothing rather than wool next to skin 2
• Avoid extremes of temperature 2

Common Pitfalls and Concerns

Corticosteroid Phobia

• 72.5% of patients worry about using topical corticosteroids, with 24% admitting non-compliance due to these concerns 6
• Most common concerns are skin thinning (34.5%) and systemic absorption (9.5%) 6
• Reality: Abnormal skin thinning occurred in only 1% of participants across 22 trials, mostly with higher-potency corticosteroids 3

Improper Potency Selection

• Using too weak a corticosteroid for moderate-severe eczema may lead to undertreatment 3
• Using too potent a corticosteroid on sensitive areas (face, genitals) increases risk of adverse effects 1

Monitoring for Complications

• Watch for signs of bacterial or viral infections that may require specific treatment 2, 1
• Monitor for skin thinning with long-term use of potent corticosteroids 3

Special Considerations for Different Body Areas

Facial Eczema

• Use only mild potency corticosteroids or calcineurin inhibitors 1
• Limit corticosteroid use to short periods (1-2 weeks) 1
• Consider tacrolimus as an alternative for longer-term management 1, 4

Body Eczema

• Moderate to potent corticosteroids can be used based on severity 2, 3
• Apply emollients liberally and frequently 2

By following these evidence-based approaches to eczema management, patients can achieve better control of their condition while minimizing potential adverse effects from treatments.