Treatment Options for Eczema
Topical corticosteroids are the mainstay of treatment for atopic eczema and should be used as first-line therapy alongside emollients for most patients with eczema. 1
First-Line Treatment Approach
Emollient Therapy
- Apply emollients liberally at least twice daily, especially after bathing 2
- Use fragrance-free formulations as soap substitutes for cleansing 2
- Emollients provide a surface lipid film that retards evaporative water loss from the epidermis 1
- Apply after bathing for maximum effectiveness 1
Topical Corticosteroids
- Use the least potent preparation required to control symptoms 1
- Select potency based on location:
- Application frequency:
- Taper once improvement occurs rather than stopping abruptly 2
Avoidance of Triggers
- Avoid soaps and detergents that remove natural skin lipids 1
- Use dispersible cream as a soap substitute 1
- Avoid irritant clothing (wool) and extremes of temperature 1
- Keep nails short to minimize damage from scratching 1
- Wear cotton clothing for comfort 1
Second-Line Treatment Options
Topical Calcineurin Inhibitors
- Pimecrolimus (Elidel) 1% cream is indicated for mild to moderate atopic dermatitis when topical corticosteroids have failed or are not advisable 2, 3
- Apply as a thin layer twice daily until symptoms resolve 2
- Not for use in children under 2 years old 3
- Should not be used continuously for long periods 3
Tar Preparations
- Ichthammol (less irritant than coal tars) can be applied as an ointment (1% ichthammol in zinc ointment) 1
- Coal tar solution (1% in hydrocortisone ointment) is generally preferred to crude coal tar 1
- Particularly useful for healing lichenified eczema when used in paste bandages 1
Antihistamines
- Primarily valuable for their sedative properties during severe pruritus flares 1
- Use as short-term adjuvant to topical treatment 1
- Non-sedating antihistamines have little to no value in atopic eczema 1
- May develop tachyphylaxis with prolonged use 1
Management of Complications
Infection Treatment
- Monitor for signs of bacterial infection (crusting, exudation, sudden worsening) 2
- For Staphylococcus aureus (most common pathogen): Flucloxacillin 1
- For penicillin-allergic patients: Erythromycin 1
- For β-hemolytic streptococci: Phenoxymethylpenicillin 1
- For herpes simplex infection (eczema herpeticum): Oral acyclovir early in course; IV acyclovir for ill, feverish patients 1
Third-Line Treatment Options
Phototherapy
- Consider for moderate to severe cases not responding to topical treatments 2
- Options include narrowband UVB and PUVA 2, 4
- Must be administered under physician guidance 2
- Long-term risks include premature skin aging and cutaneous malignancies 1
Systemic Treatments
- Reserved for severe, widespread disease unresponsive to topical therapy 2
- Options include:
- Systemic corticosteroids have a limited role in tiding over occasional patients with severe atopic eczema 1
Proactive Treatment Approach
- Long-term, low-dose intermittent application of anti-inflammatory therapy to previously affected skin 4, 6
- Helps prevent flares and stabilize skin barrier 4
- Combined with ongoing emollient treatment of unaffected skin 4
Common Pitfalls and Caveats
- Fear of topical steroids often leads to undertreatment 1
- Patient education about proper use and safety is crucial 1, 2
- Avoid high-potency steroids on the face due to risk of skin atrophy 2
- Topical calcineurin inhibitors should not be used under occlusion or with UV therapy 3
- Secondary infections can cause deterioration in previously stable eczema 1
- Bacteriological swabs are not routinely indicated but may be necessary if patients do not respond to treatment 1
By following this algorithmic approach to eczema management, starting with emollients and appropriate topical corticosteroids and escalating therapy as needed, most patients can achieve good symptom control and improved quality of life.