What are the guidelines for managing eczema?

Guidelines for Managing Eczema

The cornerstone of eczema management is a comprehensive approach that includes liberal use of fragrance-free emollients, appropriate topical anti-inflammatory treatments, trigger avoidance, and infection prevention strategies. 1

First-Line Therapy: Emollients

• Emollient Characteristics:

  • Should be fragrance-free to minimize sensitization risk
  • Applied liberally and frequently (3-8 times daily)
  • Used even when skin appears normal
  • Applied immediately after bathing to trap moisture 1

• Selection Based on Climate and Skin Condition:

  • Ointments: Better for very dry skin and winter months
  • Creams: Good balance between moisturization and cosmetic acceptability
  • Lotions: Preferred in hot, humid weather (provide less moisturization)
  • Gels: Alternative option with variable acceptance 1

• Application Technique:

  • Apply immediately after bathing while skin is still slightly damp
  • Multiple applications daily (3-8 times) for optimal barrier protection
  • Watch for signs of contact dermatitis (deterioration in previously stable eczema) 1

Anti-Inflammatory Treatment

Topical Corticosteroids

• Potency Selection Based on Severity:

  • High-potency (e.g., betamethasone dipropionate): For acute phase (2-4 weeks) of severe eczema
  • Medium-potency: For longer treatments
  • Low-potency: For mild cases and sensitive areas 1

• Application Guidelines:

  • Use for short periods (2-4 weeks) to avoid side effects (skin atrophy, telangiectasias, striae)
  • Once-daily application is as effective as twice-daily 2
  • "Get control then keep control" approach recommended 2

Topical Calcineurin Inhibitors (TCIs)

• Indications:

  • Particularly useful for sensitive sites (face, neck, intertriginous areas) 2
  • Alternative for patients who cannot tolerate topical corticosteroids

• Important Safety Considerations for Pimecrolimus (ELIDEL):

  • Not for use in children under 2 years old
  • Should not be used continuously for long periods
  • Apply only to affected areas with eczema
  • Monitor for skin infections, lymphadenopathy
  • Minimize sun exposure during treatment 3

Systemic Therapies for Moderate-to-Severe Eczema

For patients with inadequate response to topical therapies:

• Biologics (e.g., dupilumab):

  • Strongly recommended for severe, widespread, or refractory atopic dermatitis
  • Effective but expensive treatment option
  • Monitor for potential ocular side effects 1, 4

• Oral JAK Inhibitors:

  • Options include abrocitinib, baricitinib, upadacitinib
  • Emerging treatment options for severe disease 1

• Traditional Immunomodulators:

  • Cyclosporine, methotrexate, azathioprine, mycophenolate mofetil
  • Require careful monitoring 1

• Oral Corticosteroids:

  • Generally not recommended for chronic eczema due to unfavorable benefit-risk ratio 5, 4

Infection Prevention and Treatment

• For Clinically Evident Infections:

  • Treat with appropriate antibiotics
  • Consider antiseptic washes with aqueous chlorhexidine 0.05% for erosive lesions 1

• Preventive Measures:

  • Bleach baths with 0.005% sodium hypochlorite twice weekly 1
  • Note: Limited evidence supports routine use of oral or topical antistaphylococcal treatments for infected eczema 2

Trigger Management

• Environmental Factors:

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

• Dietary Considerations:

  • Elimination diets only recommended in cases of proven food allergy 4
  • Patient-specific dietary recommendations based on documented allergies

Adjunctive Therapies

• Phototherapy:

  • UV irradiation, preferably narrowband UVB or UVA1, can be beneficial 4
  • Coal tar may be useful specifically for atopic hand and foot eczema 4

• Treatments with Limited Evidence:

  • Oral antihistamines have limited effects on eczema-related itch and lesions 2, 4
  • Probiotics have not shown significant benefit for treating eczema 2
  • Silk clothing, ion-exchange water softeners, and emollient bath additives have not demonstrated benefit 2

Patient Education and Monitoring

• Eczema Action Plans (EAPs):

  • Improve parental understanding of treatment
  • Enhance provider management of eczema
  • Can be integrated into busy clinical practice 6

• Specialist Referral:

  • Consider in cases of diagnostic doubt
  • When there's failure to respond to maintenance treatment with appropriate topical steroids
  • When second-line treatment is required 1

• Patch Testing:

  • Consider for patients with persistent or recalcitrant atopic dermatitis 1

By following these evidence-based guidelines, clinicians can effectively manage eczema while enhancing patients' quality of life and minimizing disease burden.