What are the treatment options for eczema?

Treatment Options for Eczema

For effective eczema management, a stepwise approach using topical corticosteroids as first-line therapy is recommended, with potency tailored to disease severity, followed by topical calcineurin inhibitors for steroid-sparing treatment, and systemic therapies reserved for severe or refractory cases. 1

Diagnosis and Assessment

• Confirm diagnosis by identifying an itchy skin condition plus three or more of:
  • Itchiness in skin creases or cheeks
  • History of atopic disease in first-degree relatives
  • General dry skin
  • Visible eczema
  • Onset in first two years of life 1
• Assess extent, severity, signs of infection, aggravating factors, sleep disturbance, and impact on quality of life

First-Line Treatments

Non-Pharmacological Interventions

• Emollients
  • Apply liberally and frequently (3-8 times daily)
  • Use even when skin appears normal
  • Apply immediately after bathing to trap moisture
  • Choose fragrance-free formulations 1
• Bathing Practices
  • Use dispersible cream as soap substitute
  • Keep water temperature moderate
  • 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 1

Topical Corticosteroids

• Potency Selection
  • Mild potency: For mild cases, facial or genital areas
  • Moderate potency: For moderate cases or longer treatments
  • Potent: For acute flares and severe cases
  • Very potent: Reserved for severe, refractory cases 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
• Safety Considerations
  • Risk of skin atrophy, telangiectasias, and striae with prolonged use
  • Intermittent use of mild/moderate potency TCS for up to 5 years shows little to no risk of skin thinning or growth abnormalities 3

Topical Calcineurin Inhibitors

• Pimecrolimus (Elidel) 1% cream
  • Indicated for mild-to-moderate eczema in patients ≥2 years old
  • Used when topical corticosteroids are inadvisable or have failed
  • Apply thin layer to affected areas twice daily 4
  • Particularly effective for face and neck eczema 5
  • Safety warning: Long-term safety not established; rare reports of cancer (skin or lymphoma) 4

Second-Line and Advanced Treatments

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

Maintenance and Flare Prevention

• Weekend/Proactive Therapy
  • Apply topical corticosteroids twice weekly to previously affected areas
  • Reduces likelihood of relapse from 58% to 25% 2

Phototherapy

• Consider referral for phototherapy (oral PUVA) for chronic or recurrent cases
• Oral PUVA has shown 81-86% improvement or clearance for hand and foot eczema 1

Systemic Therapies

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

Referral Criteria

Refer to specialist care for:

• Diagnostic uncertainty
• Failure to respond to appropriate topical treatments
• When second-line treatment is required
• Severe, widespread, or refractory disease requiring systemic therapy 1

Common Pitfalls to Avoid

1. Using topical corticosteroids continuously for extended periods
2. Applying topical calcineurin inhibitors to children under 2 years old 4
3. Using very potent corticosteroids on face, genitals, or in young children
4. Failing to treat concurrent infections
5. Neglecting non-pharmacological measures like regular emollient use
6. Not considering environmental triggers and allergens

The evidence strongly supports a stepwise approach to eczema management, with treatment intensity matched to disease severity. While topical corticosteroids remain the cornerstone of therapy, their potency should be carefully selected based on patient age, treatment area, and disease severity, with appropriate monitoring for adverse effects.