What are the treatment options for eczema?

Treatment Options for Eczema

Topical corticosteroids are the first-line treatment for eczema, with potency selection based on severity, and should be supplemented with emollients, while systemic therapies are reserved for moderate-to-severe cases unresponsive to topical treatments. 1

Topical Treatments

Topical Corticosteroids

• Potency selection:
  • High-potency: For acute flares
  • Medium-potency: For longer treatments
  • Low-potency: For mild cases and sensitive areas 1
• Application frequency:
  • Once daily application is as effective as twice daily for potent corticosteroids 2
  • Apply as a thin layer to affected areas 3
  • Duration: Short periods (2-4 weeks) to avoid side effects 1

Proper Application Technique

• Triamcinolone acetonide cream 0.1% should be applied to affected areas 2-3 times daily 3
• Occlusive dressings may enhance efficacy for recalcitrant conditions:
  • Apply thin coating, cover with nonporous film
  • Can be applied in evening and removed in morning (12-hour occlusion) 3

Emollients

• Application guidelines:
  • Apply liberally and frequently (3-8 times daily)
  • Use even when skin appears normal
  • Apply immediately after bathing to trap moisture 1
  • Should be fragrance-free 1
• The order of application (emollient before or after corticosteroid) does not significantly affect treatment outcomes, as long as there is a 15-minute interval between applications 4

Proactive Treatment Approach

• "Get control then keep control" regimen is recommended 5
• Weekend (proactive) therapy with topical corticosteroids significantly reduces relapse rates (58% to 25%) compared to reactive treatment 2

Systemic Treatments

For moderate-to-severe eczema unresponsive to topical therapies:

• Biologics: Dupilumab
• Oral JAK inhibitors: Abrocitinib, baricitinib, upadacitinib
• Traditional immunomodulators: Cyclosporine, methotrexate, azathioprine, mycophenolate mofetil 1
• Oral prednisone (1 mg/kg/day with tapering over at least 4 weeks) may be used for short-term control 1

Managing Infections

• S. aureus colonization is common in moderate-to-severe eczema (66-71% of cases) 6
• Treatment options:
  • Appropriate antibiotics for clinically evident infections
  • Antiseptic washes with aqueous chlorhexidine 0.05% for erosive lesions
  • Bleach baths with 0.005% sodium hypochlorite twice weekly for prevention 1

Additional Therapies

• Phototherapy: Consider referral for PUVA therapy for chronic or recurrent cases 1
• Topical calcineurin inhibitors: Tacrolimus is recommended for patients ≥2 years old who are unresponsive to or intolerant of topical corticosteroids 1
  • Apply twice daily until lesions clear 1

When to Refer to a Specialist

• Diagnostic uncertainty
• Poor response to initial treatment
• Severe or widespread disease requiring systemic therapy
• Need for skin biopsy or patch testing 1

Common Pitfalls and Caveats

1. Corticosteroid phobia: 72.5% of patients worry about using topical corticosteroids, leading to non-compliance in 24% of cases 7

   • Patient education about proper use and safety is essential

2. Treatments to avoid:

   • Oral antihistamines have limited evidence for eczema treatment
   • Routine use of oral or topical antistaphylococcal treatments for non-infected eczema
   • Probiotics for treating eczema
   • Silk clothing, ion-exchange water softeners, and emollient bath additives 5

3. Risk of skin thinning:

   • Abnormal skin thinning occurs in approximately 1% of patients using topical corticosteroids
   • Risk increases with higher potency corticosteroids 2
   • Avoid prolonged use on thin skin areas (face, genitals, skin folds)

4. Antibiotic resistance:

   • Combined antibiotic/corticosteroid creams may lead to increased antibiotic resistance
   • In one study, fucidin-resistant S. aureus increased from 8% to 58% after treatment 6