What are the treatment options and dosages for managing eczema?

Management of Eczema: Treatment Options and Dosages

For effective management of eczema, a stepwise approach using topical corticosteroids as first-line therapy, with appropriate potency selection based on severity and location, is recommended, supplemented by emollients and additional therapies for specific symptoms or resistant cases.

First-Line Treatment: Topical Corticosteroids

Selection of Corticosteroid Potency

• For mild eczema, start with mild-potency topical corticosteroids 1
• For moderate to severe eczema, potent topical corticosteroids are more effective than mild preparations (70% vs 39% treatment success) 2, 3
• Very potent and potent topical corticosteroids are consistently ranked among the most effective treatments for eczema 3
• For children, use lower potencies and shorter durations to minimize adverse effects 4

Application Frequency and Duration

• Once-daily application of potent topical corticosteroids is as effective as twice-daily application 2
• Apply triamcinolone acetonide cream 0.1% to affected areas two to three times daily 5
• Use topical corticosteroids for short courses to control flares - up to 3 weeks for super-high-potency, up to 12 weeks for high/medium potency 4
• For mild/moderate atopic eczema in children, a 3-day burst of potent corticosteroid followed by base ointment for 4 days is as effective as 7 days of mild corticosteroid 6

Application Method

• Apply a thin layer to affected areas only 1, 7
• One fingertip unit (amount from fingertip to first finger crease) covers approximately 2% body surface area in adults 4
• Rub in gently 5
• Do not apply more frequently than recommended as this doesn't improve efficacy but increases risk of side effects 1

Second-Line Treatments

Topical Calcineurin Inhibitors

• Pimecrolimus cream 1% (Elidel) is indicated for patients aged 2 years and older who do not have a weakened immune system 7
• Use pimecrolimus for short periods, with breaks in between if treatment needs to be repeated 7
• Tacrolimus 0.1% is among the most effective topical treatments, with similar effectiveness to potent corticosteroids 3
• Calcineurin inhibitors are particularly useful for sensitive areas like face and skin folds where corticosteroid use is limited 3

PDE-4 Inhibitors

• Crisaborole 2% and roflumilast 0.15% are available options but ranked among the least effective treatments 3

JAK Inhibitors

• Topical JAK inhibitors like ruxolitinib 1.5% and delgocitinib 0.5% are highly effective, comparable to potent corticosteroids 3

Management of Itch

Antihistamines

• Sedating antihistamines provide the most effective symptomatic relief for pruritus 8
• Chlorphenamine 4-12 mg at night can be an alternative option 8
• Non-sedating antihistamines have little to no value in controlling itch in atopic eczema 8, 1
• Use sedating antihistamines primarily at night to avoid daytime sedation 8

Topical Anti-Pruritic Options

• Cooling antipruritic lotions such as calamine or 1% menthol in aqueous cream can provide soothing relief 8
• Ichthammol (1% in zinc ointment) may be useful for lichenified areas 8
• Coal tar solution (1%) can be considered but should be used cautiously 8

Adjunctive Therapies

Emollients

• Use emollients regularly as they provide a surface lipid film which retards evaporative water loss 1
• Apply emollients after topical corticosteroids 1
• Avoid soap and detergents as they remove natural lipids from the skin surface 1
• Use dispersible cream as a soap substitute to cleanse the skin 1

Occlusive Dressings

• May be used for management of psoriasis or other recalcitrant conditions 5
• Apply a thin coating of cream on the lesion, cover with pliable nonporous film, and seal the edges 5
• Can be applied in the evening and removed in the morning (12-hour occlusion) 5
• If infection develops, discontinue occlusive dressings and institute appropriate antimicrobial therapy 5

Treatment for Resistant Cases

Systemic Corticosteroids

• Have a limited but definite role in tiding occasional patients with severe atopic eczema 9
• Should not be considered for maintenance treatment until all other avenues have been explored 9
• Try to avoid oral corticosteroids during crises 9

Phototherapy

• PUVA (psoralen plus ultraviolet A) therapy may be considered for severe, treatment-resistant cases 1

Referral to Specialist

• Refer to a dermatologist if not responding to first-line management 1
• Indications for referral include diagnostic doubt, failure to respond to maintenance treatment, need for second-line treatment, or when specialist opinion would be valuable in counseling patients and family 9

Monitoring and Side Effects

Local Adverse Effects

• Risk of skin thinning increases with prolonged use, higher potency, occlusion, and application to areas of thinner skin 4
• Topical calcineurin inhibitors and crisaborole 2% are most likely to cause application-site reactions 3
• No evidence for increased skin thinning with short-term TCS but an increase with longer-term use 3
• Monitor for signs of skin atrophy, telangiectasia, or striae 1

Patient Education

• Address corticosteroid phobia - 72.5% of patients worry about using topical corticosteroids 10
• Explain that concerns about skin thinning (34.5% of patients) and systemic absorption (9.5%) are often disproportionate to actual risk 10
• Provide clear information about potency of different preparations - many patients cannot correctly identify potency levels 10

Special Considerations

Children

• Do not use pimecrolimus cream on children under 2 years old 7
• For children with mild/moderate eczema, a 3-day burst of potent corticosteroid followed by 4 days of base ointment is as effective as 7 days of mild corticosteroid 6
• Keep nails short to minimize damage from scratching 1

Pregnancy and Lactation

• Topical corticosteroids can work safely and effectively in patients who are pregnant or lactating 4
• Hydroxyzine is contraindicated during early pregnancy 8