What is the recommended treatment for eczema (atopic dermatitis) in pregnant women?

Treatment of Eczema in Pregnancy

The recommended treatment for eczema during pregnancy is to use emollients as first-line therapy, followed by mild to moderate potency topical corticosteroids when needed, as these have not been associated with fetal growth restriction. 1

First-Line Approach

• Emollients form the basis of therapy for atopic dermatitis during pregnancy and should be applied regularly, especially after bathing when they are most effective 2, 3
• Use a dispersible cream as a soap substitute to cleanse the skin, as soaps and detergents remove natural lipids from the skin surface 3
• Avoid known irritants and triggers such as extreme temperatures and irritant clothing (wool); cotton clothing is recommended 3

Topical Corticosteroid Use

• Topical corticosteroids remain the mainstay of treatment for atopic eczema flares during pregnancy 4, 3
• Mild to moderate potency topical corticosteroids are preferred during pregnancy due to safety considerations 1
• Potent/very potent topical corticosteroids have been associated with fetal growth restriction and should be avoided when possible 1
• Once-daily application of topical corticosteroids is as effective as twice-daily application for treating eczema flares 4
• Use the least potent preparation required to keep the eczema under control 3
• When possible, topical corticosteroids should be used for short periods and stopped when the flare resolves 3

Secondary Treatment Options

• Topical calcineurin inhibitors are considered safe treatment options during pregnancy when topical corticosteroids are insufficient 2
• Antihistamines may be useful as a short-term adjuvant to topical treatment during severe pruritic flares, primarily for their sedative properties 3
• For secondary bacterial infection, antibiotics may be necessary - flucloxacillin is usually most appropriate for Staphylococcus aureus (the most common pathogen) 3
• For herpes simplex infection (presenting as grouped, punched-out erosions), acyclovir should be given early in the course of the disease 3

Severe Eczema Requiring Specialist Management

• Refer to a dermatologist when there is:

  • Diagnostic doubt
  • Failure to respond to maintenance treatment with mild/moderate potency topical steroids
  • Need for second-line treatment 3

• Ultraviolet (UV) therapy can be considered for moderate to severe eczema during pregnancy that is not responding to topical treatments 2, 5

• For severe cases requiring systemic therapy, cyclosporin A can be used during pregnancy 2

• Data on biologics for atopic dermatitis during pregnancy are limited to small case series 2

Practical Management Tips

• Allow adequate time for explanation and discussion with pregnant patients about treatment options 3
• Demonstrate proper application of topical preparations and provide written information 3
• Document the extent and severity of eczema at each visit 3
• For patients with extensive disease, early input from dermatology specialists is essential 5
• Reassure patients that mild/moderate topical corticosteroids have not been associated with increased risk of stillbirth, preterm delivery, or congenital malformations 1

Common Pitfalls to Avoid

• Undertreatment due to fear of topical corticosteroids - this is a common issue that should be addressed through proper education 3
• Using potent/very potent topical corticosteroids when mild/moderate options would be effective 1
• Failure to recognize and treat secondary bacterial or viral infections, which can cause deterioration in previously stable eczema 3
• Neglecting the psychological impact of eczema during pregnancy, which may require additional support 5