What are the treatment options for eczema?

Treatment Options for Eczema

The management of eczema follows a stepwise approach, with topical corticosteroids being the first-line treatment for flare-ups, followed by topical calcineurin inhibitors, phototherapy, and systemic therapies for more severe cases that don't respond to initial treatments. 1

First-Line Treatment

Moisturizers and Skin Care

• Apply emollients liberally and frequently, especially after bathing
• Use soap-free cleansers for bathing
• Continue moisturizer use even when skin appears clear

Topical Corticosteroids

• Potency selection:

  • Mild eczema: Mild-potency corticosteroids
  • Moderate eczema: Moderate-potency corticosteroids
  • Severe eczema: Potent corticosteroids for short periods 1, 2

• Application frequency:

  • Once-daily application of potent corticosteroids is as effective as twice-daily application 2
  • Apply to affected areas only

• Duration:

  • Use for short periods during flares
  • Stop when signs and symptoms (itching, rash, redness) resolve 3

Topical Calcineurin Inhibitors (TCIs)

• Options include pimecrolimus (Elidel) and tacrolimus
• Particularly useful for:
  • Sensitive areas (face, neck, skin folds)
  • When concerned about steroid side effects
  • Maintenance therapy 1, 3
• Pimecrolimus is indicated for patients 2 years and older 3
• Do not use continuously for long periods 3

Second-Line Treatment

Proactive Maintenance Therapy

• Weekend (twice weekly) application of topical corticosteroids or TCIs to previously affected areas reduces relapse risk by more than 50% 2
• Helps prevent recurrent flares

Phototherapy

• Consider when topical therapies fail to control symptoms
• Narrow-band UVB is most commonly recommended 1
• May cause long-term adverse effects such as premature skin aging and cutaneous malignancies 4

Third-Line Treatment

Systemic Therapies

• Reserved for severe, recalcitrant cases that don't respond to topical treatments

• Options include:

  • Dupilumab (first FDA-approved biologic for atopic dermatitis)
  • Tralokinumab
  • JAK inhibitors
  • Immunomodulators (cyclosporine, methotrexate, azathioprine, mycophenolate mofetil) 1, 5

• Systemic corticosteroids:

  • Have limited role in severe atopic eczema
  • Should not be used for maintenance treatment
  • Can lead to rebound flares when discontinued 4, 1

Adjunctive Treatments

Infection Prevention and Management

• Bleach baths (0.005% sodium hypochlorite twice weekly) help prevent infections
• Systemic antibiotics only when clear evidence of infection 1

Antihistamines

• Limited effectiveness for eczema-related itch
• May be helpful for nighttime sedation and sleep 4, 6

Allergen Management

• Consider dietary manipulation only when history strongly suggests food allergy
• Evidence for house dust mite eradication is not strong 4

Important Considerations and Cautions

Safety of Topical Corticosteroids

• Risk of skin thinning is low when used appropriately
  • In long-term studies, only 1 case of skin atrophy was reported among 1213 patients using mild/moderate potency TCS for up to 5 years 7
• Adrenal suppression is rare with appropriate use 7
• Avoid prolonged use of high-potency corticosteroids on sensitive areas 1

Common Mistakes to Avoid

• Undertreatment due to "steroid phobia"
• Prolonged use of high-potency topical corticosteroids on sensitive areas
• Relying on antihistamines for daytime itch control
• Using systemic corticosteroids as regular treatment 1

When to Refer to a Specialist

• Failure to respond to first-line management
• Uncertain diagnosis
• Severe or widespread disease
• Need for systemic therapy 4

Special Populations

• Children under 2 years: Avoid pimecrolimus 3
• Sensitive areas (face, neck, skin folds): Prefer topical calcineurin inhibitors over corticosteroids 1

The evidence supports a structured approach to eczema management, with appropriate selection of treatments based on disease severity, affected areas, and response to initial therapy.