What are the next steps in managing moderate eczema that has not responded to moisturizer and moderate dose topical steroid (corticosteroid)?

Management of Moderate Eczema After Moisturizer and Moderate-Dose Topical Steroid Failure

For moderate eczema that has not responded to moisturizers and moderate-dose topical steroids, the next step should be to escalate to a higher potency topical corticosteroid (such as clobetasol propionate) for a short course, followed by consideration of topical calcineurin inhibitors and/or phototherapy if needed. 1

Step-Up Approach for Treatment Escalation

1. Higher Potency Topical Corticosteroids

• Switch to a potent or very potent topical corticosteroid such as clobetasol propionate 0.05% cream/ointment
• Apply a thin layer to affected areas twice daily for up to 2 weeks 2
• Important limitations:
  • Treatment should be limited to 2 consecutive weeks
  • Do not exceed 50g per week
  • Do not use with occlusive dressings
  • Discontinue when control is achieved 2

2. Optimizing Topical Corticosteroid Use

• Once-daily application of potent corticosteroids is as effective as twice-daily application 3, 4
• Consider weekend/proactive therapy (applying topical corticosteroids twice weekly) to prevent relapses after initial control is achieved 3
• For dry, scaly lesions, consider using a corticosteroid formulation with emollients for better efficacy 5

3. Topical Calcineurin Inhibitors (TCIs)

• If no improvement after 2 weeks of potent corticosteroid or concerns about steroid side effects:
  • Add pimecrolimus cream 1% (Elidel) to sensitive areas (face, neck, intertriginous areas) 1, 6
  • Apply twice daily to affected areas
  • Particularly useful for maintenance therapy and steroid-sparing effect 1
  • Avoid in children under 2 years of age 6

4. Phototherapy

• Consider if topical treatments fail to control symptoms
• Narrow-band UVB is the most commonly recommended form 1
• Requires referral to dermatology for administration

5. Systemic Therapy Options

• For severe, recalcitrant cases not responding to above measures:
  • Dupilumab (first FDA-approved biologic for atopic dermatitis)
  • Cyclosporine (rapid onset of action)
  • Methotrexate (slower onset but better tolerated long-term)
  • Azathioprine
  • Mycophenolate mofetil 1

Practical Management Tips

Addressing Common Pitfalls

• Undertreatment due to "steroid phobia" is common - educate on proper use and safety 1, 7
• Only 17% of patients understand corticosteroid potency classifications 7
• Avoid prolonged use of high-potency steroids on sensitive areas (face, genitals, axillae)
• Do not use systemic corticosteroids as regular treatment due to risk of rebound flares 1

Infection Prevention and Treatment

• Consider bleach baths with 0.005% sodium hypochlorite twice weekly to help prevent infections
• Use systemic antibiotics only when there is clear evidence of infection 1
• For suspected viral infections (eczema herpeticum), prompt antiviral therapy is essential

Maintenance Strategies

• Continue regular emollient use even after resolution of active eczema
• Apply emollients liberally and frequently, especially after bathing
• Use soap-free cleansers for bathing 1
• Identify and eliminate triggering substances
• Avoid irritant clothing and extremes of temperature 1

When to Refer to a Dermatologist

• No improvement after 2 weeks of potent topical corticosteroid therapy 8
• Suspected complications (e.g., secondary infection)
• Need for phototherapy or systemic treatments
• Diagnostic uncertainty

By following this step-up approach, most cases of moderate eczema that have failed initial therapy with moisturizers and moderate-potency topical steroids can be effectively managed.