What is the best treatment for eczema?

Best Treatment for Eczema

Topical corticosteroids are the first-line treatment for eczema, with potency selection based on severity: mild potency for mild cases, medium potency for moderate cases, and high potency for acute severe flares, used for short periods (2-4 weeks) to minimize side effects. 1

Treatment Algorithm

Non-Pharmacological Interventions (First Steps)

• Emollients: Apply liberally and frequently (3-8 times daily)
  • Use immediately after bathing to trap moisture
  • Choose fragrance-free products
  • Continue even when skin appears normal 1
• Bathing practices:
  • Use dispersible cream as soap substitute
  • Apply emollients immediately after bathing 1
• Environmental modifications:
  • Keep nails short to minimize damage from scratching
  • Use cotton clothing
  • Avoid temperature extremes
  • Consider air purifiers to reduce PM 2.5 exposure, especially during dry moderate weather 1

Pharmacological Treatment

1. Topical Corticosteroids (TCS)

   • Mild eczema: Low-potency TCS
   • Moderate eczema: Medium-potency TCS
   • Severe/acute flares: High-potency TCS (for 2-4 weeks only)
   • Application frequency: Once daily application of potent TCS is as effective as twice daily application 2
   • Duration: Short periods (2-4 weeks) to avoid side effects such as skin atrophy, telangiectasias, and striae 1
   • Maintenance: Consider weekend therapy (proactive approach) to prevent relapses 2

2. Topical Calcineurin Inhibitors (TCIs)

   • Pimecrolimus (Elidel): For mild-to-moderate eczema
   • Important safety note: Should be avoided on malignant or pre-malignant skin conditions 3
   • Precautions: May cause local symptoms such as skin burning or pruritus, especially during first few days of application 3
   • Contraindications: Not for use in patients with Netherton's Syndrome or generalized erythroderma 3

3. Infection Management

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

Advanced Therapies for Moderate-to-Severe Eczema

When topical therapies are inadequate:

1. Biologics (e.g., dupilumab)
2. Oral JAK inhibitors (e.g., abrocitinib, baricitinib, upadacitinib)
3. Traditional immunomodulators (e.g., cyclosporine, methotrexate, azathioprine, mycophenolate mofetil) 1

When to Refer to Specialist

• Diagnostic uncertainty
• Failure to respond to appropriate topical steroids
• Need for second-line treatment 1

Important Considerations and Pitfalls

Safety of Long-term Topical Corticosteroid Use

• Recent evidence suggests intermittent use of mild/moderate potency TCS for up to 5 years results in little to no difference in skin thinning when used to treat flares 4
• Abnormal skin thinning is rare (1% of patients in trials) but risk increases with higher potency TCS 2
• No cases of clinical adrenal insufficiency were reported with mild/moderate TCS use in a three-year RCT 4

Common Pitfalls to Avoid

1. Undertreatment: Using too low potency TCS for moderate-severe eczema

   • Moderate-potency TCS are probably more effective than mild-potency (52% vs 34% treatment success) 2
   • Potent TCS are probably more effective than mild-potency (70% vs 39% treatment success) 2

2. Overtreatment: Using very potent TCS unnecessarily

   • Evidence is uncertain regarding advantage of very potent over potent TCS 2

3. Infection management: Bacterial or viral infections at treatment sites should be resolved before starting treatment with TCIs like pimecrolimus 3

4. Sun exposure: Patients using pimecrolimus should minimize natural or artificial sunlight exposure 3

5. Inappropriate use of systemic corticosteroids: These have a limited role and should not be considered for maintenance treatment until all other options have been explored 1