What is the recommended treatment for eczema?

Treatment of Eczema (Atopic Dermatitis)

The recommended treatment for eczema involves a stepwise approach starting with emollients and topical corticosteroids, with potency selection based on severity, and considering calcineurin inhibitors for sensitive areas or when corticosteroids are ineffective. 1

First-Line Management

Non-Pharmacological Interventions

• Emollients (moisturizers):

  • Apply liberally and frequently (3-8 times daily)
  • Use immediately after bathing to trap moisture
  • Continue using even when skin appears normal
  • Choose fragrance-free formulations 1

• Bathing practices:

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

• Environmental modifications:

  • Wear cotton clothing
  • Keep nails short to minimize damage from scratching
  • Avoid temperature extremes
  • Consider air purifiers to reduce PM 2.5 exposure, especially during dry moderate weather 1

Pharmacological Interventions

Topical Corticosteroids (First-line)

• Potency selection based on severity:

  • Mild eczema: Low-potency (e.g., hydrocortisone 1%)
  • Moderate eczema: Medium-potency corticosteroids
  • Severe/acute flares: High-potency corticosteroids 1, 2

• Application frequency:

  • Once-daily application of potent corticosteroids is as effective as twice-daily application 2
  • Use for short periods (2-4 weeks) to avoid side effects 1

• Application technique:

  • Apply a thin layer only to affected areas
  • The order of application between emollients and corticosteroids does not significantly impact efficacy (parents can choose preferred order) 3
  • Allow 15 minutes between applying emollient and corticosteroid 3

• Maintenance therapy:

  • Weekend therapy (proactive approach) significantly reduces relapse rates (from 58% to 25%) compared to reactive treatment 2

Topical Calcineurin Inhibitors (Second-line)

• Pimecrolimus (Elidel):
  • For patients aged 2 years and older
  • Use when other prescription medicines have not worked or are not recommended
  • Apply thin layer to affected areas twice daily
  • For short periods with breaks between treatments 4
  • Less effective than moderate and potent corticosteroids and 0.1% tacrolimus 5
  • Common side effects include burning sensation at application site, usually resolving within days 4

Safety Considerations

Topical Corticosteroids

• Risk of skin thinning is low (1% in clinical trials) when used appropriately 2
• Higher potency corticosteroids carry greater risk of skin thinning 2
• Long-term intermittent use (up to 5 years) of mild/moderate potency corticosteroids shows little to no difference in skin thinning, growth abnormalities, or adrenal insufficiency 6
• Patient concerns about corticosteroids often exceed actual risks - 72.5% of patients worry about using them, with 24% reporting non-compliance due to these concerns 7

Topical Calcineurin Inhibitors

• FDA safety concerns: small number of people using pimecrolimus have had cancer (skin or lymphoma), though direct causation not established
• Should not be used continuously for long periods
• Avoid in children under 2 years
• Avoid use with sun exposure, tanning beds, or UV light therapy 4

When to Consider Systemic Therapies

• For moderate-to-severe atopic dermatitis with inadequate response to topical therapies
• Options include:
  • Biologics (e.g., dupilumab)
  • Oral JAK inhibitors (e.g., abrocitinib, baricitinib, upadacitinib)
  • Traditional immunomodulators (e.g., cyclosporine, methotrexate) 1

When to Refer to a Specialist

• Diagnostic uncertainty
• Failure to respond to appropriate topical steroid treatment
• Need for second-line treatments
• Persistent or recalcitrant atopic dermatitis
• Consideration for phototherapy (oral PUVA) for chronic cases 1

Common Pitfalls to Avoid

1. Undertreatment due to steroid phobia - educate patients that appropriate use of topical corticosteroids has minimal risk 7
2. Continuous use of high-potency steroids - limit to 2-4 weeks to prevent side effects 1
3. Neglecting maintenance therapy - weekend/proactive therapy significantly reduces relapse rates 2
4. Overlooking infections - treat clinically evident infections with appropriate antibiotics; consider antiseptic washes with aqueous chlorhexidine 0.05% for erosive lesions 1
5. Using pimecrolimus as first-line therapy - it's less effective than corticosteroids and should be reserved for when corticosteroids have failed or are contraindicated 5