What are the treatment options for eczema?

Treatment Options for Eczema

The most effective approach to treating eczema is a stepwise strategy beginning with topical therapies as first-line treatment, progressing to phototherapy and systemic therapies for more severe or refractory cases. 1

First-Line Treatments: Topical Therapies

Topical Corticosteroids

• Primary anti-inflammatory treatment for flares

  • Apply twice daily for up to 4 weeks initially 1
  • Once daily application is likely as effective as twice daily for potent corticosteroids 2
  • Potency selection based on severity:
    • Mild eczema: Mild potency
    • Moderate eczema: Moderate potency
    • Severe eczema: Potent corticosteroids
    • High-potency (Class 1-2) reserved for thick, lichenified, or treatment-resistant lesions 1

• "Get control then keep control" approach:

  • After improvement, reduce frequency to 1-2 times weekly to prevent flares 1, 3
  • Weekend (proactive) therapy significantly reduces relapse likelihood from 58% to 25% 2

• Safety considerations:

  • Monitor for skin atrophy, striae, telangiectasia, and purpura 1
  • Risk of skin thinning is low (only 1% in clinical trials) but increases with higher potency 2
  • Long-term intermittent use (up to 5 years) shows reassuring safety data for growth and skin thinning 4

Topical Calcineurin Inhibitors (TCIs)

• Strongly recommended for mild to moderate eczema 1
• Particularly valuable for sensitive areas (face, neck, skin folds) due to no risk of skin atrophy 1
• Pimecrolimus (Elidel) considerations:
  • Approved for patients 2 years and older 5
  • Should not be used continuously for long periods 5
  • Use only on areas with eczema 5
  • Safety warning: A very small number of people using TCIs have developed cancer, though a direct link has not been established 5

Other Topical Options

• Topical PDE-4 inhibitors (e.g., crisaborole): Strongly recommended for mild to moderate eczema 1
• Topical JAK inhibitors: Strongly recommended for mild to moderate eczema 1

Skin Care Essentials

• Emollients:

  • Apply 3-8 times daily, even when skin appears normal 1
  • Use fragrance-free products 1
  • Apply immediately after bathing to lock in moisture 1
  • Ointments provide maximum occlusion (best for very dry skin/winter)
  • Creams offer good balance of hydration and acceptability 1
  • Order of application: No significant difference whether emollient is applied before or after corticosteroids (15-minute interval between applications) 6

• Bathing recommendations:

  • Use gentle, pH-neutral synthetic detergents instead of soap 1
  • Avoid irritants such as perfumes, deodorants, and alcohol-based lotions 1

Second-Line Treatment: Phototherapy

• Conditionally recommended for moderate to severe eczema when topical therapies are insufficient 1
• Narrowband UVB is generally preferred, especially for adolescents 1
• Should be administered under specialist supervision 1

Third-Line Treatment: Systemic Therapies

Biologics

• Strongly recommended for severe, widespread, or refractory eczema 1
• Options include dupilumab and tralokinumab 1

Oral JAK Inhibitors

• Strongly recommended for severe, widespread, or refractory eczema 1
• Options include abrocitinib, baricitinib, and upadacitinib 1

Immunomodulators

• Conditionally recommended for severe, widespread, or refractory eczema 1
• Options include cyclosporine, methotrexate, azathioprine, and mycophenolate 1

Systemic Corticosteroids

• Generally not recommended due to rebound flares upon discontinuation and adverse effects with long-term use 1
• May be considered as short-term intervention (<7 days) for severe acute exacerbations when other options have failed 1

Managing Infections

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

Trigger Management

• Identify and eliminate triggering substances 1
• Reduce PM 2.5 exposure, especially during dry moderate weather conditions 1
• Consider air purifiers for indoor environments 1

Common Pitfalls to Avoid

1. Undertreatment: Don't hesitate to use appropriate potency corticosteroids for adequate duration
2. Overuse of oral antihistamines: Limited evidence supports their use for eczema 3
3. Overuse of antimicrobial treatments: Little evidence supports routine use for non-infected eczema 3
4. Prolonged continuous use of topical corticosteroids: Use "get control then keep control" approach instead
5. Delaying referral: Consider specialist care for diagnostic doubt, treatment failure, or when second-line treatment is needed 1