What are the treatment options for eczema?

Treatment Options for Eczema

A stepwise approach beginning with topical therapies is the recommended first-line treatment for most patients with eczema, with phototherapy and systemic therapies reserved for more severe or refractory cases. 1

First-Line Treatments: Topical Therapies

Topical Corticosteroids

• Potent and moderate topical corticosteroids are more effective than mild corticosteroids for treating eczema, particularly for moderate to severe cases 2, 3
• Apply twice daily for up to 4 weeks initially for flares 1
• Once-daily application of potent topical corticosteroids is as effective as twice-daily application 2, 4
• Potency selection guidelines:
  • Mild (Class 5-7): Face, genitals, skin folds, infants
  • Moderate (Class 3-4): Trunk, extremities, children
  • Potent/Very potent (Class 1-2): Reserved for thick, lichenified, or treatment-resistant lesions 1
• Weekend therapy (proactive approach) applying topical corticosteroids twice weekly can prevent flares after improvement 1, 2
• Monitor for adverse effects including skin atrophy, striae, telangiectasia, and purpura 1

Topical Calcineurin Inhibitors

• Strongly recommended for mild to moderate eczema, particularly for sensitive areas 1
• No risk of skin atrophy, making them suitable for long-term use 1
• Examples include:
  • Tacrolimus 0.1% - ranked among the most effective topical treatments 3
  • Pimecrolimus (Elidel) - less effective than moderate/potent corticosteroids and 0.1% tacrolimus 5
• Pimecrolimus should not be used:
  • Continuously for long periods
  • In children under 2 years old
  • In patients with weakened immune systems 6
• Most common side effects include burning or warmth sensation at application site 6, 5

Topical PDE-4 Inhibitors

• Crisaborole 2% is strongly recommended for mild to moderate eczema 1
• May cause application site reactions more commonly than topical steroids 3

Topical JAK Inhibitors

• Strongly recommended for mild to moderate eczema 1
• Ruxolitinib 1.5%, delgocitinib 0.5% or 0.25% ranked among most effective topical treatments 3

Second-Line Treatment: Phototherapy

• Conditionally recommended for moderate to severe eczema when topical therapies are insufficient 1
• Narrowband UVB is generally preferred for adolescents, under specialist supervision 1
• Safe and effective for moderate to severe atopic dermatitis when first-line treatments are inadequate 7

Third-Line Treatments: Systemic Therapies

Biologics

• Strongly recommended for severe, widespread, or refractory eczema 1
• Examples include dupilumab and tralokinumab 1, 7

Oral JAK Inhibitors

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

Immunomodulators

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

Systemic Corticosteroids

• Conditionally recommended against 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

Skin Care and Prevention

• Apply fragrance-free emollients 3-8 times daily, even when skin appears normal 1
• Preferably apply emollients immediately after bathing to lock in moisture 1
• Use gentle, pH-neutral synthetic detergents instead of soap 1
• Avoid irritants such as perfumes, deodorants, and alcohol-based lotions 1
• Identify and eliminate triggering substances 1
• Consider air purifiers to reduce PM 2.5 exposure, especially during dry moderate weather conditions 1

Infection Prevention and Treatment

• Treat clinically evident infections 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
• Evidence does not support routine use of oral or topical antistaphylococcal treatments for infected eczema 4

Important Considerations and Pitfalls

1. Avoid under-treatment: More aggressive use of topical therapies using the "get control then keep control" regimen is recommended 4

2. Avoid unnecessary treatments:

   • Oral antihistamines are not recommended as they do not reduce pruritus 4, 7
   • Silk clothing, ion-exchange water softeners, and emollient bath additives have not shown benefit 4
   • Probiotics have not been shown effective for treating eczema 4

3. Safety monitoring:

   • Risk of skin thinning is low with short-term use of topical steroids (1% across studies) 2
   • Skin thinning risk increases with higher potency steroids 2
   • Long-term use (6-60 months) of topical steroids showed skin thinning in only 0.3% of participants 3

4. When to refer to specialists:

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