What is the treatment for nummular eczema?

Treatment for Nummular Eczema

Topical corticosteroids are the first-line treatment for nummular eczema, with potency selection based on severity and location, supplemented by emollients and identification of triggers. 1

First-Line Treatment Approach

Topical Anti-inflammatory Therapy

• Topical corticosteroids:

  • For moderate to severe nummular eczema: Potent topical corticosteroids (e.g., mometasone furoate 0.1%)
  • For mild cases: Low to moderate potency (e.g., hydrocortisone 0.1-2.5%, clobetasone butyrate 0.05%)
  • For facial involvement: Use low-potency corticosteroids only
  • Apply once or twice daily until improvement (effectiveness is similar between once daily and twice daily application) 1, 2
  • Duration: Short-term use (2-4 weeks) to control acute flares

• Topical calcineurin inhibitors (TCIs):

  • Pimecrolimus 1% cream or tacrolimus 0.03%/0.1% ointment
  • Particularly useful for sensitive areas (face, intertriginous areas) where corticosteroids may cause atrophy 1, 3
  • Apply twice daily to affected areas

Skin Care Essentials

• Emollients:

  • Apply liberally at least twice daily, especially after bathing
  • Use fragrance-free formulations or urea-containing (5-10%) products
  • Apply after topical medications for optimal absorption 1

• Bathing recommendations:

  • Use gentle, pH-neutral non-soap cleansers
  • Avoid hot water and harsh soaps
  • Pat skin dry and apply emollients immediately after bathing 1

Second-Line and Adjunctive Therapies

For Moderate to Severe or Recalcitrant Cases

• Wet-wrap therapy:

  • Effective short-term treatment for moderate to severe cases
  • Apply for 3-7 days (up to 14 days in severe cases) 1

• Antihistamines:

  • May help relieve pruritus as adjunctive therapy
  • Non-sedating options: cetirizine, loratadine, fexofenadine 1

• Phototherapy:

  • Consider for adults with inadequate response to topical treatments
  • Not recommended for children under 12 years 1

For Severe Refractory Cases

• Systemic therapy options:
  • Methotrexate: Effective in children with severe nummular eczema (81% showed >50% improvement) 4
  • Dupilumab: Effective for nummular eczema phenotype of atopic dermatitis in adults 5
  • Other options: cyclosporine, azathioprine
  • Should be managed by dermatology specialists 1

Prevention and Maintenance

Proactive Management

• Weekend therapy (proactive approach):

  • Apply topical corticosteroids twice weekly to previously affected areas after clearing
  • Significantly reduces relapse rates (from 58% to 25%) 1, 2

• Allergen identification and avoidance:

  • Consider patch testing for patients with chronic or persistent nummular eczema
  • Avoid identified triggers 1, 6

Special Considerations

Monitoring for Complications

• Watch for signs of infection:

  • Crusting, exudation, sudden worsening
  • Treat bacterial infections with appropriate antibiotics 1

• Monitor for adverse effects:

  • Skin thinning occurs in approximately 1% of patients using topical corticosteroids, with higher risk from very potent formulations 2
  • Risk increases with higher potency and longer duration of use

Follow-up

• Reassess after 2 weeks of treatment to evaluate response
• If no improvement, consider:
  • Changing treatment approach
  • Referral to dermatologist
  • Reevaluating diagnosis 1

Common Pitfalls to Avoid

• Using potent topical corticosteroids on the face for prolonged periods
• Neglecting to identify and avoid triggers
• Using topical antihistamines (can cause sensitization)
• Long-term use of topical antibiotics without confirmed infection
• Discontinuing treatment after initial improvement without maintenance therapy 1, 6

The prognosis for nummular eczema is generally good with proper treatment, though the condition can be chronic with relapses and remissions requiring ongoing management 6.