What are the management options for chronic eczema?

Management of Chronic Eczema

The most effective approach to chronic eczema management involves a stepwise treatment strategy starting with liberal emollient use and topical corticosteroids as first-line therapy, progressing to topical calcineurin inhibitors, phototherapy, and systemic immunosuppressants for refractory cases. 1

First-Line Treatment

Emollient Therapy

• Apply emollients 3-8 times daily, even when skin appears normal, as the foundation of eczema management 1
• Use ointments rather than creams for dry, irritable rashes as they provide better barrier function
• Apply at least once daily to the entire body, more frequently on affected areas
• Avoid alcohol-containing products which can worsen dryness

Topical Corticosteroids

• Use mild potency topical corticosteroids (e.g., 1% hydrocortisone) for mild flares and in sensitive areas 1
• Apply twice daily for short periods (7-14 days) to treat flares
• For moderate flares not responding to mild steroids, use medium potency steroids like 0.05% clobetasone butyrate for short periods
• Return to mild steroid or emollient-only therapy after resolution
• Consider "weekend therapy" with mild steroids to prevent relapses 1

Infection Management

• Monitor for signs of secondary infection (increased redness, weeping, crusting)
• Use antiseptics on erosive lesions (e.g., aqueous chlorhexidine 0.05%)
• Consider bleach baths with 0.005% sodium hypochlorite twice weekly to prevent infections
• Use systemic antibiotics only when there is clear evidence of infection 1

Second-Line Treatment

Topical Calcineurin Inhibitors

• Pimecrolimus cream 1% (Elidel) is indicated for patients age 2 years and older who have not responded to other prescription medicines 2
• Apply a thin layer only to affected areas twice daily
• Use for short periods, and if needed, treatment may be repeated with breaks in between
• Avoid continuous long-term use due to potential safety concerns 2
• Do not use in children under 2 years of age

Phototherapy

• Consider for cases not responding to topical treatments 1
• Options include narrow-band UVB, broadband UVB, and UVA1
• PUVA therapy can be particularly effective for hand eczema, with significant improvement in 81-86% of patients 1
• Be aware of potential risks including premature skin aging and cutaneous malignancies, particularly with PUVA 3

Third-Line Treatment

Systemic Therapy

• Systemic corticosteroids have a limited but definite role in tiding occasional patients with severe atopic eczema 3
• Should not be considered for maintenance treatment until all other options have been explored
• For moderate to severe cases, dupilumab has shown the highest efficacy among biological treatments 4
• Other systemic options include:
  • Cyclosporine (considered the gold standard systemic therapy)
  • Methotrexate
  • Azathioprine
  • Mycophenolate mofetil 4, 5

Special Considerations

Allergen Avoidance

• Consider food allergies in infants with severe eczema, particularly if eczema persists despite optimized management 1
• The role of house dust mites in atopic eczema is not strongly supported by evidence for eradication benefits 3
• Identify and eliminate triggering substances and avoid irritant clothing 1

Psychological Support

• Patient support groups and contact with other patients or parents can help reduce feelings of helplessness and isolation 3
• Consider cognitive behavioral techniques such as relaxation therapy
• Access to a clinical psychologist is recommended for severe cases 3

Common Pitfalls

• "Steroid phobia" often leads to insufficient treatment and prolonged suffering 1
• Using potent steroids unnecessarily increases the risk of side effects
• Applying topical corticosteroids to the face, diaper area, and skin folds should be avoided unless specifically directed 1
• Deterioration in previously stable eczema may indicate secondary infection or contact dermatitis 1

When to Refer to a Specialist

• Diagnostic doubt
• Failure to respond to maintenance treatment with appropriate topical steroids
• When second-line treatment is required
• When specialist opinion would be valuable in counseling patients and family 3

By following this evidence-based approach to chronic eczema management, most patients can achieve significant improvement in their condition and quality of life.