What are the treatment options for eczema?

Treatment Options for Eczema

The first-line treatment for eczema includes daily emollients as foundation therapy, with topical corticosteroids of appropriate potency for active inflammation, and topical calcineurin inhibitors for sensitive areas or long-term management. 1

Foundation Therapy

Emollients and Moisturizers

• Apply fragrance-free emollients 3-8 times daily, even when skin appears normal 1
• Apply immediately after bathing to lock in moisture
• Ointments provide maximum occlusion (best for very dry skin)
• Creams offer a good balance of hydration and acceptability (less greasy) 1

Anti-inflammatory Treatments

Topical Corticosteroids (TCS)

• Potency selection based on location and severity:

  • Medium-potency: For body (trunk and extremities)
  • Low-potency: For face, neck, and intertriginous areas 1
  • Once-daily application is as effective as twice-daily for potent corticosteroids 1, 2

• Duration considerations:

  • Use low-potency TCS for short periods (<2 weeks)
  • Limit medium-potency use to 4 weeks to minimize adverse effects 1
  • Long-term intermittent use (weekend/proactive therapy) significantly reduces flare risk (58% to 25%) 2

• Safety profile:

  • Risk of skin atrophy increases with potency
  • Abnormal skin thinning occurs in approximately 1% of patients using TCS, mostly with higher potencies 2
  • Long-term intermittent use (up to 5 years) likely causes little to no skin thinning or growth abnormalities 3

Topical Calcineurin Inhibitors (TCIs)

• Pimecrolimus (Elidel) 1% cream:

  • FDA-approved for patients ≥2 years with mild-to-moderate eczema 4
  • Indicated when other prescription medicines have failed or are not recommended 4
  • Does not cause skin atrophy, making it ideal for sensitive areas 1
  • 71% of patients achieve clear or almost clear status after 8 weeks 1
  • Apply twice daily to affected areas 4

• Tacrolimus ointment:

  • Preferred for moderate-to-severe eczema
  • More effective than pimecrolimus for overall disease control 5
  • Particularly effective for facial atopic dermatitis 1

• Safety considerations for TCIs:

  • Do not use continuously for long periods
  • FDA warning about potential cancer risk, though causation not established 4
  • Burning sensation is common but typically resolves within days 5

Managing Infections

• For signs of infection:
  • Use antiseptic washes with aqueous chlorhexidine 0.05% 1
  • Consider bleach baths with 0.005% sodium hypochlorite twice weekly 1
  • Oral antibiotics if clinically indicated (e.g., doxycycline 100mg twice daily or minocycline 50mg twice daily for 6 weeks) 1

Lifestyle Modifications

• Use gentle, pH-neutral synthetic detergents instead of soap 1
• Avoid irritants: perfumes, deodorants, alcohol-based lotions 1
• Avoid irritant clothing and extremes of temperature 1
• Keep nails short to minimize damage from scratching 1
• Consider air purifiers to reduce PM 2.5 exposure 1

Treatment Algorithm

1. Mild eczema:

   • Daily emollients
   • Low-potency TCS for flares (face/sensitive areas)
   • Medium-potency TCS for flares (body)
   • Consider pimecrolimus for face/sensitive areas

2. Moderate eczema:

   • Daily emollients
   • Medium-potency TCS for body flares
   • TCIs for face/sensitive areas
   • Consider proactive weekend therapy with TCS to prevent flares

3. Severe eczema:

   • Daily emollients
   • Medium to potent TCS for acute flares
   • TCIs for face/sensitive areas
   • Consider phototherapy (narrowband UVB) for widespread disease 1, 6
   • Referral to dermatologist for consideration of systemic therapy (e.g., dupilumab) 1

When to Refer to Specialist

• Diagnostic uncertainty
• Poor response to first-line treatment after 2-3 weeks
• Need for second-line treatments
• Very severe or widespread disease 1

Common Pitfalls and Caveats

• Underuse of emollients: They are the foundation of management and should be continued even when skin appears normal
• Overuse of topical corticosteroids: Limit use on sensitive areas to avoid atrophy
• Inappropriate potency selection: Match corticosteroid potency to body location and disease severity
• Neglecting proactive therapy: Weekend use of TCS significantly reduces flare risk
• Ignoring infection: Secondary infection can worsen eczema and requires specific treatment
• TCI application discomfort: Warn patients about potential burning sensation that typically resolves within days