What are the treatment options for eczema?

Treatment Options for Eczema

Topical corticosteroids are the first-line therapy for eczema, with potency selection based on severity and location, followed by maintenance therapy using intermittent application (1-2× weekly) to prevent flares after disease stabilization. 1

First-Line Treatment: Topical Corticosteroids

Potency Selection

• Medium-potency: For body areas
• Low-potency: For face, neck, and intertriginous areas
• High-potency (Class 1-2): Reserved for thick, lichenified, or treatment-resistant lesions 1

Application Guidelines

• Apply twice daily for up to 4 weeks as initial treatment
• Reassess after 2 weeks to evaluate response
• Once-daily application is as effective as twice-daily for potent corticosteroids 1, 2
• Prolonged use of medium to high-potency steroids beyond 4 weeks increases risk of skin atrophy 1

Maintenance Phase

• After improvement, reduce frequency to 1-2 times weekly to prevent flares
• This "proactive therapy" approach decreases likelihood of relapse from 58% to 25% 1, 2

Emollients and Skin Care

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

Second-Line Treatments

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% and 0.03% are effective alternatives, particularly for sensitive areas
• Useful for face, neck, and intertriginous areas where steroid-induced skin atrophy is a concern
• May cause application site reactions more frequently than topical corticosteroids 1, 3, 4

Infection Management

• Treat clinically evident infections with appropriate antibiotics
• Consider antiseptic washes with aqueous chlorhexidine 0.05% for erosive lesions
• Bleach baths with 0.005% sodium hypochlorite twice weekly can help prevent infections 1

Advanced Therapies for Severe, Refractory Cases

Biologics and Systemic Agents

• Dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib are strongly recommended for severe, refractory cases 1
• JAK inhibitors (ruxolitinib 1.5%, delgocitinib) show high effectiveness in recent studies 3, 4

Phototherapy

• Consider narrowband UVB for moderate to severe cases not responding to topical treatments
• Generally preferred for adolescents, under specialist supervision 1

Trigger Avoidance and Lifestyle Modifications

• Identify and eliminate triggering substances
• Use gentle, pH-neutral synthetic detergents instead of soap
• Avoid irritants such as perfumes, deodorants, and alcohol-based lotions
• Avoid extremes of temperature
• Keep nails short to prevent damage from scratching 1

Treatments to Avoid or Use with Caution

• Systemic corticosteroids are not recommended due to risk of rebound flares 1
• Limited evidence supports oral antihistamines, oral or topical antistaphylococcal treatments for infected eczema, or probiotics 5
• Nonpharmacological treatments including silk clothing, ion-exchange water softeners, and emollient bath additives have not shown significant benefit 5

When to Refer to Specialist Care

Referral is recommended in cases of:

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

Monitoring for Adverse Effects

• Watch for skin atrophy, striae, telangiectasia, and purpura with topical corticosteroids
• Short-term use of topical steroids (median 3 weeks) shows minimal risk of skin thinning, but longer-term use (6-60 months) may increase risk 1, 3
• Application site reactions are more common with tacrolimus 0.1% and crisaborole 2% than with topical corticosteroids 3, 4