What is the recommended treatment for eczema?

Recommended Treatment for Eczema

The recommended first-line treatment for eczema is high-potency topical corticosteroids for the acute phase (2-4 weeks), followed by medium-potency corticosteroids for longer treatments, with emollients applied multiple times daily as essential maintenance therapy. 1

Treatment Algorithm Based on Severity

Mild Eczema

• Low-potency topical corticosteroids (e.g., hydrocortisone) 1
• Apply once daily (effectiveness similar to twice daily application) 2
• Fragrance-free emollients applied 3-8 times daily, even when skin appears normal 1
  • Best applied immediately after bathing to lock in moisture 1

Moderate to Severe Eczema

1. Acute phase (2-4 weeks): High-potency topical corticosteroids (e.g., betamethasone dipropionate)

   • 94.1% good or excellent clinical response in studies 1
   • Apply once daily (as effective as twice daily for potent corticosteroids) 2

2. Maintenance phase: Medium-potency corticosteroids 1

   • Use for longer treatments to minimize side effects

3. For inadequate response to topical therapies:

   • Phototherapy: PUVA (Psoralen plus UVA) therapy 1

     • Oral PUVA superior to UVB for hand eczema (81-86% improvement/clearance)

   • Systemic therapies for refractory cases: 1

     • Biologics (e.g., dupilumab)
     • Oral JAK inhibitors (e.g., abrocitinib, baricitinib, upadacitinib)
     • Traditional immunomodulators (e.g., cyclosporine, methotrexate)

4. Second-line therapy for patients who don't respond to topical corticosteroids:

   • Topical calcineurin inhibitors like pimecrolimus (Elidel) 3
     • For adults and children ≥2 years old
     • Not for continuous long-term use
     • Less effective than moderate and potent corticosteroids 4

Application Technique

• Order of application (emollient vs. corticosteroid) does not significantly affect treatment outcomes 5
• Allow 15 minutes between applications 5
• For moisturizers with topical medications, apply the medication first, then moisturizer 3

Prevention and Maintenance

• Weekend therapy (proactive approach): Apply topical corticosteroids twice weekly to prevent flares
  • Reduces relapse risk from 58% to 25% 2
• Identify and eliminate triggering substances 1
• Reduce PM 2.5 exposure, especially during dry moderate weather 1
• Consider air purifiers for indoor environments 1

Infection Management

• 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

Important Cautions and Monitoring

• Limit topical corticosteroid use to 2-4 weeks to avoid side effects such as skin atrophy, telangiectasias, and striae 1
• Monitor for signs of skin thinning, particularly with higher-potency corticosteroids 2
• Abnormal skin thinning occurs in approximately 1% of patients, more commonly with higher-potency corticosteroids 2
• Long-term studies (up to 5 years) suggest intermittent use of mild/moderate potency corticosteroids results in minimal risk of skin thinning 6
• Address patient concerns about topical corticosteroids, as 72.5% of patients worry about their use, which can affect treatment compliance 7

When to Refer to a Specialist

• Diagnostic uncertainty
• Failure to respond to appropriate topical steroid treatment
• When second-line treatment is required
• For patch testing in persistent or recalcitrant cases 1