What are the treatment options for eczema?

Treatment Options for Eczema

The most effective treatment approach for eczema involves a stepwise regimen starting with emollients and topical corticosteroids, progressing to calcineurin inhibitors for sensitive areas, and considering systemic therapies for severe cases. 1

First-Line Treatments

Emollients (Moisturizers)

• Apply liberally and frequently (3-8 times daily)
• Use immediately after bathing to trap moisture
• Continue even when skin appears normal
• Choose based on:
  • Patient preference (improves adherence)
  • Climate and season
  • Skin dryness (ointments for very dry skin, creams for balanced moisturization, lotions for hot weather) 1

Bathing Recommendations

• Beneficial for cleansing and hydrating skin
• Use dispersible creams as soap substitutes
• Apply emollients immediately after bathing 1

Topical Corticosteroids

• Primary anti-inflammatory treatment
• Potency selection:
  • Mild eczema: Low-potency (e.g., hydrocortisone)
  • Moderate eczema: Medium-potency
  • Severe/acute flares: High-potency (for 2-4 weeks) 1, 2
• Apply once daily (similar effectiveness to twice daily with fewer side effects) 2, 3
• "Get control then keep control" approach is recommended 3
• For flare prevention: Consider weekend/proactive therapy (applying twice weekly) which reduces relapse risk from 58% to 25% 2

Important: Reassure patients about corticosteroid safety when used appropriately, as fear often leads to undertreatment. Studies show 72.5% of patients worry about using topical corticosteroids, with 24% admitting non-compliance due to these concerns 4

Second-Line Treatments

Topical Calcineurin Inhibitors (TCIs)

• Pimecrolimus (Elidel) and tacrolimus are effective alternatives to corticosteroids
• Particularly useful for sensitive areas (face, neck, skin folds)
• Pimecrolimus (Elidel) specifics:
  • Approved for patients ≥2 years old
  • Use for short periods with breaks between treatments
  • Not for continuous long-term use
  • Apply a thin layer twice daily to affected areas 5
  • Not for use in immunocompromised patients 5

Safety note: TCIs carry a boxed warning about potential cancer risk, though a direct link has not been established. Use only as directed and for appropriate duration 5

Infection Management

Treating Infections

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

Evidence note: There is limited evidence supporting routine use of oral or topical antistaphylococcal treatments for infected eczema 3

Advanced Therapies for Moderate-to-Severe Eczema

Phototherapy

• Consider for chronic or recurrent cases
• Oral PUVA (Psoralen + UVA) shows superior efficacy to UVB for hand eczema
• Can achieve significant improvement in 81-86% of hand and foot eczema cases 1

Systemic Therapies

• For moderate-to-severe eczema unresponsive to topical treatments
• Options include:
  • Biologics (e.g., dupilumab)
  • Oral JAK inhibitors (e.g., abrocitinib, baricitinib, upadacitinib)
  • Traditional immunomodulators (e.g., cyclosporine, methotrexate) 1

Trigger Management

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

When to Refer to a Specialist

• Diagnostic uncertainty
• Failure to respond to appropriate topical treatments
• Need for second-line or systemic treatments
• For patch testing in persistent or recalcitrant cases 1

What to avoid: Evidence does not support the use of oral antihistamines, probiotics, silk clothing, ion-exchange water softeners, or emollient bath additives for treating eczema 3