What are the treatment guidelines for eczema?

Treatment Guidelines for Eczema

Low-potency topical corticosteroids are the first-line treatment for mild to moderate eczema, with medium-potency preparations reserved for short-term use (2-4 weeks) in moderate to severe cases. 1

First-Line Treatments

Topical Corticosteroids

• Potency selection:

  • Mild eczema: Low-potency topical corticosteroids
  • Moderate to severe eczema: Medium-potency topical corticosteroids for short-term use (2-4 weeks)
  • Avoid long-term use of potent topical corticosteroids on the face
  • Avoid potent topical corticosteroids in children under 2 years 1

• Application frequency:

  • Once-daily application of potent topical corticosteroids is as effective as twice-daily application 2
  • Apply after bathing to lock in moisture 1
  • Short bursts (3 days) of potent corticosteroids can be as effective as prolonged use (7 days) of mild preparations 3

• Maintenance therapy:

  • Twice-weekly application of topical corticosteroids to previously affected areas significantly reduces relapse likelihood from 58% to 25% 1, 2

Moisturizers and Emollients

• Apply liberally and frequently, especially after bathing 1
• Use soap-free cleansers for bathing 1
• Order of application (emollient vs. corticosteroid) does not significantly affect treatment outcomes 4
• Allow 15 minutes between applications of different products 4

Second-Line Treatments

Topical Calcineurin Inhibitors (TCIs)

• Pimecrolimus (Elidel) 1% cream:

  • For patients 2 years and older 5
  • Indicated when other prescription medicines have not worked or are not recommended 5
  • Apply twice daily to affected areas 5, 6
  • More frequent application (4 times daily) does not increase efficacy 6
  • Particularly useful for sensitive areas like face and skin folds 1
  • Should not be used continuously for long periods 5

• Tacrolimus 0.03% ointment:

  • More efficacious than 1% hydrocortisone in children with moderate to severe eczema 7
  • Can be applied once or twice daily, with twice daily being more effective for severe cases 7

Crisaborole

• Approved for patients aged 3 months and above with mild to moderate eczema 1

Advanced Therapies for Moderate to Severe Cases

• Phototherapy
• Immunosuppressants
• Biologics 1

Management of Complications

Bacterial Infections

• Obtain bacterial cultures
• Administer appropriate antibiotics if secondary infection is suspected 1
• Avoid long-term use of topical antibiotics due to resistance risk 1

Viral Infections (Eczema Herpeticum)

• Treat with prompt systemic antiviral therapy
• Intravenous acyclovir for severe cases
• Oral acyclovir as standard first-line treatment 1

Practical Considerations and Pitfalls

Common Pitfalls to Avoid

1. Using potent topical corticosteroids on the face for prolonged periods
2. Neglecting to identify and avoid triggers
3. Using topical antihistamines (risk of sensitization)
4. Long-term use of topical antibiotics
5. Long-term use of oral corticosteroids (unfavorable risk-benefit profile) 1

Special Considerations

• For children under 2 years: Avoid pimecrolimus cream 5
• For sensitive areas (face, genitals, skin folds): Use TCIs or low-potency corticosteroids 1
• For pregnant/breastfeeding patients: Consult physician before using TCIs 5

Sun Exposure

• Limit sun exposure during treatment with TCIs
• Avoid sun lamps, tanning beds, or ultraviolet light therapy during treatment 5
• Wear loose-fitting clothing that protects treated areas when outdoors 5

Patient Education

• Deterioration in previously stable eczema may indicate secondary infection or contact dermatitis 1
• Dietary restrictions have little benefit in adults but may be considered in selected infants under professional supervision 1
• Identify and eliminate triggering substances 1
• Avoid irritant clothing 1
• Avoid extremes of temperature 1
• Keep nails short to minimize damage from scratching 1

By following these evidence-based guidelines, most patients with eczema can achieve significant improvement in their symptoms and quality of life.