What are the treatment options for eczema?

Treatment Options for Eczema

The cornerstone of eczema treatment is a comprehensive approach including liberal use of fragrance-free emollients, appropriate topical anti-inflammatory medications, trigger avoidance, and infection prevention strategies. 1

First-Line Treatment: Emollient Therapy

• Apply fragrance-free emollients liberally and frequently (3-8 times daily)
• Apply immediately after bathing while skin is still slightly damp to trap moisture
• Continue using emollients even when skin appears normal
• Choose emollients based on:
  • Patient preference (increases adherence)
  • Climate/season (ointments for very dry skin/winter; creams for balanced moisturization; lotions for hot/humid weather)
  • Avoid fragranced products to minimize sensitization risk

Topical Anti-Inflammatory Treatments

Topical Corticosteroids (TCS)

• Match potency to disease severity:

  • Mild eczema: Low-potency TCS (e.g., hydrocortisone 1%)
  • Moderate eczema: Medium-potency TCS
  • Severe eczema: Potent TCS (e.g., betamethasone dipropionate) for acute phase (2-4 weeks)
  • Very severe/recalcitrant: Very potent TCS may be considered

• Application frequency:

  • Once-daily application of potent TCS is as effective as twice-daily application 2
  • Use for short periods (2-4 weeks) to avoid side effects like skin atrophy
  • For maintenance, consider weekend/proactive therapy (twice weekly application) to prevent flares

Topical Calcineurin Inhibitors (TCIs)

• Pimecrolimus (Elidel) 1% cream:

  • For mild-to-moderate eczema in patients ≥2 years old
  • Use when other prescription medicines have not worked or are not recommended 3
  • Apply thin layer to affected areas twice daily
  • Not for continuous long-term use due to theoretical cancer risk concerns 3
  • May cause burning sensation at application site

• Tacrolimus 0.1%:

  • More effective than pimecrolimus for moderate-to-severe eczema 4, 5
  • Consider for steroid-sensitive areas (face, genitals, skin folds)

Newer Topical Agents

• PDE-4 inhibitors (e.g., crisaborole, roflumilast)
• JAK inhibitors (e.g., ruxolitinib, delgocitinib)
  • Ruxolitinib 1.5% ranks among the most effective topical treatments 5

Infection Prevention and Management

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

Treatment Algorithm

1. For all patients with eczema:

   • Liberal use of fragrance-free emollients (3-8 times daily)
   • Identify and avoid triggers
   • Consider environmental modifications (air purifiers, reducing PM 2.5 exposure)

2. For mild eczema:

   • Low-potency TCS once daily for flares (2-4 weeks)
   • Consider TCIs for steroid-sensitive areas

3. For moderate eczema:

   • Medium-potency TCS once daily for flares (2-4 weeks)
   • Consider weekend/proactive therapy to prevent flares

4. For severe eczema:

   • Potent TCS once daily for acute flares (2-4 weeks)
   • Step down to medium-potency TCS for longer treatments
   • Consider referral for phototherapy (oral PUVA) for chronic/recurrent cases

5. For very severe/refractory eczema:

   • Consider biologics (e.g., dupilumab) or oral JAK inhibitors
   • Referral to dermatology specialist

Important Considerations and Pitfalls

• Order of application: The order of applying emollients and TCS does not significantly affect treatment outcomes - parents can apply in whichever order they prefer 6
• TCS phobia: Many patients (72.5%) worry about using TCS, leading to non-compliance (24%) 7. Provide clear education about safety and proper use.
• Monitoring for side effects:
  • TCS: Watch for skin thinning, telangiectasias, and striae with prolonged use
  • TCIs: Monitor for application site reactions (burning sensation)
  • Avoid TCIs in patients with skin infections
• When to refer: Consider specialist referral for:
  • Diagnostic uncertainty
  • Failure to respond to appropriate topical treatments
  • Need for second-line systemic therapies

Remember that consistent emollient use and appropriate anti-inflammatory treatment are key to successful eczema management. Patient education about proper application techniques and addressing concerns about medication safety are crucial for treatment adherence.