What is the recommended treatment for severe eczema with high IgE to dust mite and molluscum contagiosum?

Management of Severe Eczema with Dust Mite Allergy and Molluscum Contagiosum

For severe eczema with dust mite allergy and molluscum contagiosum, a comprehensive treatment approach should include topical corticosteroids as first-line therapy, with consideration of systemic immunomodulators for refractory cases, while addressing the molluscum contagiosum separately. 1

First-Line Treatment

Topical Therapy

• Apply potent topical corticosteroids twice daily to affected areas during flares, as these are consistently ranked among the most effective topical treatments for severe eczema 2, 3
• Use the least potent preparation that effectively controls symptoms to minimize side effects 4
• For facial eczema, use mild to moderate potency corticosteroids due to the thinner skin in this area 4
• Apply emollients (moisturizers) at least once daily to the whole body, preferably oil-in-water creams or ointments rather than alcohol-containing lotions 5, 4
• Consider using a dispersible cream as a soap substitute for cleansing to prevent further drying of the skin 5

Managing Molluscum Contagiosum

• Treat molluscum contagiosum separately, as it can worsen when combined with eczema (eczema molluscatum) 6
• Be cautious with topical immunomodulators like tacrolimus in patients with molluscum contagiosum, as they may exacerbate the viral infection 6
• Consider referral to a dermatologist for treatment of the molluscum contagiosum lesions 1

Allergen Management

• Despite high IgE to dust mites, evidence for benefits of dust mite eradication is not strong, and currently there are no effective measures for complete eradication 1
• Continue avoiding walnuts and pecans based on the food allergy test results 1
• A trial of dietary manipulation may be indicated when widespread active eczema is not responding to first-line treatment 1

Second-Line Treatment

Topical Calcineurin Inhibitors

• Consider tacrolimus 0.1% for areas where potent steroids are contraindicated (face, skin folds), as it ranks among the most effective topical treatments 2, 3
• Pimecrolimus 1% is approved for atopic dermatitis in patients 2 years and older who do not have a weakened immune system 7
• Be aware that topical calcineurin inhibitors are more likely to cause application site reactions compared to topical corticosteroids 2, 3

Phototherapy

• Consider narrowband ultraviolet B (NB-UVB, 312 nm) therapy if accessible and practical, as it has shown efficacy for moderate-to-severe eczema 1
• PUVA (psoralen plus ultraviolet A) therapy can be considered but carries long-term risks of skin aging and cutaneous malignancies 1
• Phototherapy should be considered before systemic therapy if accessible and practical 1

Third-Line Treatment (For Refractory Cases)

Systemic Therapy

• Cyclosporine is recommended as first-option systemic treatment for patients with atopic eczema refractory to conventional treatment 8
• Azathioprine has shown effectiveness in randomized controlled trials for severe eczema 1, 8
• Systemic corticosteroids have a limited but definite role in tiding occasional patients with severe atopic eczema, but should not be considered for maintenance treatment 1
• Methotrexate and mycophenolate mofetil may be considered as alternative systemic agents 1

When to Refer to a Specialist

• Diagnostic doubt 1
• Failure to respond to maintenance treatment with mildly potent steroids in children or moderately potent steroids in adults 1
• When second-line treatment is required or dietary manipulation is being tried 1
• When specialist opinion would be valuable in counseling patients and family 1

Important Considerations and Pitfalls

• Avoid long-term use of very potent topical corticosteroids, especially on the face, as they can cause skin thinning 2, 9
• Be aware that applying potent topical corticosteroids once daily is likely as effective as twice daily application 9
• Weekend (proactive) therapy with topical corticosteroids can help prevent flare-ups in patients with frequent relapses 9
• Patients with eczema may also benefit from cognitive behavioral techniques such as relaxation therapy or self-hypnosis 1
• Chinese herbal medicines have been reported to be effective in some cases but carry a risk of hepatotoxicity; regular liver function tests are recommended if this approach is chosen 1