Treatment Options for Eczema
Topical corticosteroids are the mainstay of treatment for eczema and should be used with the least potent preparation required to control symptoms, alongside proper emollient therapy and avoidance of triggers. 1
First-Line Treatment Approach
Avoidance of Provoking Factors
- Avoid soaps and detergents that remove natural skin lipids; use dispersible cream as a soap substitute 1
- Wear cotton clothing instead of irritant materials like wool 1
- Keep nails short to minimize damage from scratching 1
- Avoid extreme temperatures that can trigger flare-ups 1
Bathing and Emollients
- Regular bathing is beneficial for both cleansing and hydrating the skin 1
- Apply emollients after bathing when they are most effective at creating a protective lipid film 1
- Allow patients to determine the most suitable bath oil and bathing regimen for their condition 1
Topical Corticosteroids
- Use the least potent preparation required to control symptoms 1
- For moderate to severe eczema, moderate to potent corticosteroids are probably more effective than mild preparations 2
- Once-daily application of potent corticosteroids is likely as effective as twice-daily application for treating flare-ups 2
- Topical corticosteroids should be applied no more than twice daily; some newer preparations require only once-daily application 1
- Common patient concerns about skin thinning and systemic effects are often disproportionate to actual risks when used appropriately 3
Second-Line Treatment Options
Tar Preparations
- Ichthammol (1% in zinc ointment) is less irritant than coal tar and particularly useful for lichenified eczema 1
- Coal tar solution (1%) can be used with hydrocortisone ointment 1
- Tar preparations generally don't cause systemic side effects unless used excessively 1
Antihistamines
- Primarily valuable for their sedative properties during severe pruritus episodes 1
- Non-sedating antihistamines have little to no value in atopic eczema 1
- Should be used as short-term adjuvants to topical treatment during relapses 1
- Best administered while asleep; daytime use should be avoided 1
Management of Infection
- Antibiotics are important for treating secondary bacterial infection 1
- Flucloxacillin is usually most appropriate for Staphylococcus aureus (most common pathogen) 1
- Phenoxymethylpenicillin for β-hemolytic streptococci 1
- Erythromycin for penicillin-allergic patients or resistant cases 1
- Eczema herpeticum (herpes simplex infection) requires oral acyclovir; intravenous administration for febrile patients 1
Prevention of Relapse
- Weekend (proactive) topical corticosteroid therapy significantly reduces likelihood of relapse compared to reactive treatment 2
- This approach decreases relapse rates from 58% to 25% 2
Third-Line Treatment Options
Phototherapy
- Narrow-band ultraviolet B (312 nm) may be beneficial 1
- Long-term adverse effects such as premature skin aging and cutaneous malignancies are concerns, particularly with PUVA therapy 1
Systemic Treatments
- Systemic corticosteroids have a limited but definite role for severe atopic eczema 1
- Should not be considered for maintenance treatment until all other options have been explored 1
- Should be avoided during crises if possible 1
Special Considerations
Order of Application
- The order of application between emollients and topical corticosteroids does not significantly affect treatment outcomes 4
- Parents/patients can apply medications in whichever order they prefer 4
Safety Concerns
- Risk of pituitary-adrenal suppression increases with higher potency corticosteroids, large surface area application, prolonged use, and occlusive dressings 5
- Abnormal skin thinning is relatively rare (about 1% of patients in clinical trials), with most cases associated with higher-potency corticosteroids 2
- Patient education about proper use and safety of topical corticosteroids is essential to improve compliance 3