What is the best treatment for an eczema flareup?

Treatment for Eczema Flare-ups

For eczema flare-ups, the most effective first-line treatment is a combination of liberal emollient use and appropriate potency topical corticosteroids, with medium potency corticosteroids for maintenance and high/very potent corticosteroids reserved for severe flares. 1

First-Line Treatment Strategy

Emollient Therapy

• Apply emollients 3-8 times daily, even when skin appears normal 1
• Use ointments rather than creams for dry, irritable rashes (better hydration by improving skin's lipid barrier) 1
• Apply at least once daily to the entire body, more frequently on affected areas 1
• Avoid alcohol-containing products which can worsen dryness 1

Topical Corticosteroid Therapy

1. Selection based on severity:

   • Mild flares: Use mild potency corticosteroids (e.g., 1% hydrocortisone)
   • Moderate flares: Use medium potency corticosteroids (e.g., 0.05% clobetasone butyrate)
   • Severe flares: Use high/very high potency corticosteroids 1

2. Application guidelines:

   • Apply twice daily during flares 1
   • For moderate flares not responding to mild steroids, use a short burst (3 days) of moderate potency steroid 1
   • Limit continuous use to 2 weeks maximum 1
   • Once daily application of potent topical corticosteroids is likely as effective as twice daily application 2
   • Avoid applying to face, diaper area, and skin folds unless specifically directed 1

Important Considerations

Infection Management

• Resolve bacterial or viral infections at treatment sites before starting treatment 3
• Monitor for signs of secondary infection 1
• Consider bleach baths with 0.005% sodium hypochlorite twice weekly to prevent infections 1
• Use systemic antibiotics only when clear evidence of infection exists 1

Avoiding Common Pitfalls

• "Steroid phobia": Often leads to insufficient treatment and prolonged suffering 1
• Overuse of potent steroids: Increases risk of side effects including skin thinning 1, 4
• Ignoring triggers: Identify and eliminate triggering substances and avoid irritant clothing 1
• Application-site reactions: Topical calcineurin inhibitors (tacrolimus, pimecrolimus) are more likely to cause application-site reactions than topical corticosteroids 4

Second-Line Treatments

Topical Calcineurin Inhibitors

• Consider for areas where topical corticosteroids are not suitable (face, skin folds) 1
• Tacrolimus 0.1% is more effective than pimecrolimus 1% 4
• May cause local symptoms such as skin burning or pruritus, especially during first few days 3
• Should not be used on malignant or pre-malignant skin conditions 3

Phototherapy

• Consider for cases not responding to topical treatments 1
• Options include narrow-band UVB, broadband UVB, and UVA1 1
• PUVA therapy shows significant improvement in 81-86% of patients with hand eczema 1
• Potential risks include premature skin aging and cutaneous malignancies 1

Maintenance and Prevention

Proactive Treatment

• Weekend therapy (applying topical corticosteroids twice weekly) after flare resolution can prevent relapses 1, 4
• Proactive therapy reduces likelihood of relapse from 58% to 25% 2

Long-term Management

• Continue liberal emollient use (3-8 times daily) for maintenance after flare resolution 1
• Identify and address potential food allergies, particularly in infants with severe eczema 1
• Keep nails short to prevent damage from scratching 1

When to Refer to Specialist Care

• Diagnostic uncertainty
• Failure to respond to appropriate topical steroids
• When second-line treatment is required 1

Remember that abnormal skin thinning is rare with short-term use of topical corticosteroids (even potent ones) but may increase with longer-term use 4. Balancing effectiveness against potential side effects is essential for optimal eczema management.