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 used for short periods (2-4 weeks) to avoid side effects such as skin atrophy. 1

First-Line Treatments

Topical Corticosteroids (TCS)

• Potency selection based on severity:
  • High-potency: For acute flares
  • Medium-potency: For longer treatments
  • Low-potency: For mild cases and sensitive areas (face, genitals, skin folds)
• Application frequency: Once daily application is as effective as twice daily for potent corticosteroids 2, 3
• Duration: Short periods (2-4 weeks) to avoid side effects 1
• Risk of skin thinning: Low with short-term use (1-16 weeks), but increases with longer-term use (6-60 months) 3

Emollients

• Application: Apply liberally and frequently (3-8 times daily)
• Characteristics: Should be fragrance-free
• Timing: Apply immediately after bathing to trap moisture
• Continued use: Use even when skin appears normal 1

Second-Line Treatments

Topical Calcineurin Inhibitors (TCIs)

• Indications: For patients ≥2 years old who are unresponsive to or intolerant of topical corticosteroids 1
• Options:
  • Tacrolimus 0.1%: Highly effective, similar to potent TCS 3
  • Tacrolimus 0.03%: For milder cases
  • Pimecrolimus 1% (Elidel): For sensitive areas
• Application: Thin layer to affected areas twice daily until lesions clear 1
• Safety note: Should not be used continuously for long periods due to theoretical cancer risk 4
• Side effects: More likely to cause application site reactions than TCS 3

Newer Topical Agents

• JAK inhibitors (e.g., ruxolitinib 1.5%, delgocitinib 0.5%): Highly effective, similar to potent TCS 3
• PDE-4 inhibitors (e.g., crisaborole 2%, roflumilast): Less effective than TCS and TCIs 3

Prevention of Flares

Proactive (Weekend) Therapy

• Approach: Apply topical anti-inflammatories twice weekly to previously affected areas even when clear
• Effectiveness: Reduces likelihood of relapse from 58% to 25% 2
• Duration: Can be used long-term with breaks in between treatments 1, 5

Infection Management

• Clinically evident infections: Treat with appropriate antibiotics
• Prevention: Consider bleach baths with 0.005% sodium hypochlorite twice weekly 1
• For erosive lesions: Consider antiseptic washes with aqueous chlorhexidine 0.05% 1

Systemic Treatments for Moderate-to-Severe Eczema

When to Consider Systemic Therapy

• Inadequate response to optimized topical therapy
• Severe, widespread disease
• Significant impact on quality of life

Options

• Biologics: Dupilumab
• JAK inhibitors: Abrocitinib, baricitinib, upadacitinib
• Traditional immunomodulators: Cyclosporine, methotrexate, azathioprine, mycophenolate mofetil
• Short-term oral corticosteroids: Prednisone (1 mg/kg/day) with tapering over at least 4 weeks 1

Additional Therapies

• Phototherapy: Consider referral for phototherapy (oral PUVA) for chronic or recurrent cases 1
• Patch testing: Consider for patients with persistent or recalcitrant atopic dermatitis 1

Common Pitfalls to Avoid

• Overuse of topical corticosteroids: Can lead to skin atrophy, telangiectasias, and striae
• Undertreatment: Using too weak a potency for the severity of eczema
• Inappropriate use of antibiotics: Only use for clinically evident infections, not for prevention 5
• Reliance on antihistamines: Little evidence supports their continued use for eczema 5
• Use of unproven therapies: Silk clothing, ion-exchange water softeners, and emollient bath additives have not been shown to benefit eczema patients 5

When to Refer to a Specialist

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