What is the treatment for eczema?

Treatment of Eczema

The cornerstone of eczema treatment is a stepwise approach starting with liberal use of emollients, followed by topical corticosteroids matched to disease severity, with topical calcineurin inhibitors, phototherapy, and systemic agents reserved for more severe or resistant cases. 1

First-Line Treatment

Moisturizers and Skin Care

• Apply emollients liberally and frequently, especially after bathing to lock in moisture
• Use soap-free cleansers for bathing
• Continue emollient use even after resolution to prevent recurrence 1

Topical Corticosteroids (TCS)

• Potency selection based on severity:

  • Mild eczema: Mild-potency TCS (e.g., hydrocortisone)
  • Moderate eczema: Moderate-potency TCS
  • Severe eczema: Potent TCS for short courses
  • Very severe/thick lesions: Very potent TCS for short courses 1, 2

• Application frequency:

  • Once-daily application of potent TCS is as effective as twice-daily application 2
  • For hydrocortisone, apply to affected area not more than 3-4 times daily 3
  • Children under 2 years: Consult a doctor before using 3

• Duration:

  • If no improvement after 2 weeks of potent TCS, consider treatment escalation 1
  • For maintenance, consider proactive therapy with twice-weekly application to previously affected areas to prevent flares 1, 2

Second-Line Treatment

Topical Calcineurin Inhibitors (TCIs)

• Consider for:
  • Maintenance therapy
  • Sensitive areas (face, genitals, skin folds)
  • When concerned about steroid side effects
• Tacrolimus 0.1% ranks among the most effective topical treatments 1, 4
• Note: May cause application site reactions more commonly than TCS 4

Phototherapy

• Recommended when topical therapies fail to control symptoms
• Narrow-band UVB is the most commonly recommended form
• Consider potential long-term adverse effects (premature skin aging, cutaneous malignancies) 1

Third-Line Treatment

Systemic Therapies

• Consider for severe, recalcitrant cases:
  • Dupilumab (first FDA-approved biologic for atopic dermatitis)
  • JAK inhibitors (ruxolitinib, delgocitinib)
  • Traditional immunomodulators (cyclosporine, methotrexate, azathioprine, mycophenolate mofetil)
• Cyclosporine has rapid onset but methotrexate may be better tolerated long-term 1, 4

Infection Prevention and Management

• Bleach baths with 0.005% sodium hypochlorite twice weekly can help prevent infections
• Use systemic antibiotics only when clear evidence of infection 1

Trigger Management

• Identify and eliminate triggering substances
• Avoid irritant clothing and extremes of temperature
• Keep nails short to minimize damage from scratching 1

Common Pitfalls to Avoid

1. Undertreatment due to "steroid phobia"

   • Despite concerns, studies show that appropriate TCS use for up to 5 years results in minimal skin thinning when used intermittently 5, 6
   • Only 0.3% of participants using longer-term TCS reported skin thinning 5

2. Prolonged use of high-potency TCS on sensitive areas

   • Reserve potent/very potent TCS for short courses
   • Use lower potency TCS or TCIs for sensitive areas 1

3. Relying on antihistamines for daytime pruritus control

   • Antihistamines have limited effectiveness for eczema-related itch
   • May be helpful primarily for nighttime sedation and sleep 1

4. Using systemic corticosteroids as regular treatment

   • Can lead to rebound flares when discontinued
   • Should not be used for maintenance treatment 1

5. Dietary manipulation without evidence of food allergy

   • Consider only when history strongly suggests food allergy 1

When to Refer to a Specialist

• Failure to respond to first-line management
• Uncertain diagnosis
• Severe or widespread disease
• Need for systemic therapy 1

The evidence strongly supports a stepwise approach to eczema treatment, with emollients and appropriate-potency TCS forming the foundation of therapy. Recent evidence from network meta-analyses indicates that potent TCS, JAK inhibitors, and tacrolimus 0.1% are among the most effective topical treatments 4, while concerns about TCS side effects appear largely unfounded when used appropriately 5, 6.