Eczema: Definition and Management
Eczema is an itchy inflammatory skin condition characterized by multiple pinpoint lesions, polymorphism (erythema, papules, vesicles, scaling), and dry skin that requires a stepwise treatment approach starting with emollients and topical corticosteroids as first-line therapy. 1, 2
Diagnostic Features of Eczema
Eczema (atopic dermatitis) is diagnosed based on:
- Essential criterion: Itchy skin condition or report of scratching 3
- Plus three or more of:
- History of itchiness in skin creases (elbow folds, neck, or cheeks in children under 4)
- History of asthma/hay fever (or family history in young children)
- General dry skin in the past year
- Visible flexural eczema (or affecting cheeks/forehead in young children)
- Onset in first two years of life 3
Clinically, eczema presents with:
- Acute phase: Erythema, papules, vesicles, seropapules, pustules, scaling, and crusting 2
- Chronic phase: Lichenification, skin thickening, and hyperpigmentation 2
Management Algorithm
Step 1: Basic Skin Care and Trigger Avoidance
- Apply emollients 3-8 times daily, even when skin appears normal 1
- Use fragrance-free emollients immediately after bathing 1
- Choose appropriate formulation:
- Ointments: Maximum occlusion for very dry skin
- Creams: Less greasy, good balance of hydration and acceptability 1
- Avoid irritants:
Step 2: Topical Corticosteroids (First-line Therapy)
- Apply topical corticosteroids once daily (as effective as twice daily) 1, 4
- Match steroid potency to location:
- Low-potency: Face, neck, intertriginous areas
- Medium-potency: Body
- High-potency (Class 1-2): Reserved for thick, lichenified, or treatment-resistant lesions 1
- Initial treatment: Apply for up to 4 weeks with reassessment after 2 weeks 1
- Use "get control then keep control" approach: After improvement, reduce to 1-2 applications weekly for maintenance 1, 4
Step 3: Second-line Topical Treatments
- Topical calcineurin inhibitors (tacrolimus 0.1%) for sensitive sites and steroid-sparing approach 1, 5
- Janus kinase inhibitors (ruxolitinib 1.5%, delgocitinib) are among the most effective topical treatments 5
Step 4: Management of Complications
- For infected eczema:
Step 5: Referral and Advanced Therapies
- Refer to specialist when:
- Diagnostic uncertainty exists
- Failure to respond to appropriate topical treatments
- Second-line treatment is required 1
- Advanced therapies:
- Phototherapy (narrowband UVB) for moderate-severe cases
- Systemic therapies: Dupilumab, tralokinumab, JAK inhibitors (abrocitinib, baricitinib, upadacitinib) for severe, refractory cases 1
Important Cautions and Pitfalls
- Avoid prolonged use of medium to high-potency steroids beyond 4 weeks due to risk of skin atrophy 1
- Monitor for steroid side effects: Skin atrophy, striae, telangiectasia, and purpura 1
- Avoid ineffective treatments:
- Oral antihistamines have limited evidence for treating eczema
- Routine use of oral/topical antistaphylococcal treatments for non-infected eczema
- Silk clothing, ion-exchange water softeners, and emollient bath additives lack evidence of benefit 4
- Systemic corticosteroids are not recommended due to risk of rebound flares 1
Patient Education
- Demonstrate application techniques for topical preparations
- Provide written information to reinforce discussed issues
- Discuss realistic expectations about treatment outcomes
- Address impact on sleep, school/work, and quality of life 3
Remember that eczema is a chronic condition requiring consistent management. The goal is to control symptoms, prevent flares, and maintain skin barrier function while minimizing treatment side effects.