What is the recommended treatment for persistent eczema?

Treatment for Persistent Eczema

For persistent eczema, a stepwise approach using topical corticosteroids as first-line therapy is recommended, with medium potency corticosteroids for maintenance and higher potency for severe flares, supplemented by proper skin care and emollients. 1

First-Line Treatment Approach

Topical Corticosteroids

• Initial therapy:
  • Medium potency topical corticosteroids (TCS) for most body areas 1, 2
  • Low potency TCS for sensitive areas (face, neck, intertriginous areas) 1
  • Apply once daily (effectiveness is similar to twice daily application for potent TCS) 2
  • For severe flares, use high/very potent TCS initially 1

Maintenance Therapy

• Proactive approach: Apply medium potency TCS twice weekly to previously affected areas to prevent relapses 1, 2
  • This "weekend therapy" significantly reduces relapse risk (from 58% to 25%) 2
  • Continue even after visible resolution of lesions 1

Emollient Therapy

• Apply emollients multiple times daily to entire body, more frequently on affected areas 1
• Use ointments rather than creams for dry, irritable rashes (better hydration) 1
• Avoid alcohol-containing products which worsen dryness 1

Second-Line Treatments

For Inadequate Response to Topical Corticosteroids

• Phototherapy options:
  • PUVA therapy shows superior efficacy (81-86% improvement) for hand and foot eczema 1
  • Consider for cases not responding to topical treatments 1

For Severe, Recalcitrant Cases

• Immunomodulators:
  • Cyclosporine, methotrexate, or azathioprine 1
• Biologics:
  • Dupilumab for severe, recalcitrant cases 1, 3

Special Considerations

Managing Complications

• For fissures: Apply propylene glycol 50% in water for 30 minutes under plastic occlusion nightly, followed by hydrocolloid dressing 1
• For infection risk:
  • Watch for signs of secondary infection (usually Staphylococcus aureus) 1
  • Consider bleach baths with 0.005% sodium hypochlorite twice weekly 1
  • Use systemic antibiotics only when clear evidence of infection exists 1

Precautions with Topical Corticosteroids

• Monitor for adverse effects:
  • Risk of skin thinning increases with higher potency TCS, but overall incidence is low (1%) 2, 4
  • Avoid occlusive dressings with higher potency TCS unless specifically indicated 5
  • Children may absorb proportionally larger amounts of TCS and require closer monitoring 5
  • Long-term intermittent use of mild/moderate TCS appears safe regarding growth abnormalities and skin thinning 4

Practical Application Tips

• Potency selection:

  • Potent and moderate TCS are more effective than mild TCS for moderate/severe eczema 2
  • Short bursts (3 days) of potent TCS can be as effective as prolonged use (7 days) of mild preparations 6

• Application technique:

  • Apply as a thin film to affected areas 5
  • For maintenance, use the least amount compatible with effective control 5

• Trigger management:

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

Pitfalls to Avoid

• Overuse of topical corticosteroids: Can lead to HPA axis suppression, particularly with potent TCS over large areas or with occlusive dressings 5
• Undertreatment: Insufficient potency or duration can lead to persistent symptoms and reduced quality of life 2
• Neglecting maintenance therapy: Stopping treatment completely after resolution often leads to rapid relapse 1, 2
• Ignoring secondary infection: Deterioration in previously stable eczema may indicate secondary infection 1