What are the treatment options for eczema?

Treatment Options for Eczema

Topical corticosteroids are the mainstay of treatment for eczema, with the least potent preparation that effectively controls symptoms being recommended as first-line therapy. 1, 2, 3

First-Line Treatment

Topical Corticosteroids

• Choose the least potent preparation that effectively controls the eczema 1, 2
• For facial eczema, use mild to moderate potency corticosteroids due to thinner skin in this area 1
• Apply treatment once or twice daily - once-daily application of potent corticosteroids is equally effective as twice-daily application 1, 4
• Regular application for 2-3 weeks is typically required depending on severity 5
• Potent and moderate topical corticosteroids are more effective than mild corticosteroids for moderate to severe eczema 4, 6

Skin Care and Trigger Management

• Apply emollients immediately after bathing to provide a surface lipid film that retards evaporative water loss 1, 2, 3
• Use dispersible cream as a soap substitute instead of regular soaps and detergents that remove natural skin lipids 1, 2
• Avoid extreme temperatures and irritant clothing (such as wool); cotton clothing is preferred 1, 2
• Keep nails short to minimize damage from scratching and reduce risk of secondary infection 1, 2

Second-Line Treatment Options

Alternative Topical Preparations

• Ichthammol (1% in zinc ointment) for lichenified eczema - less irritant than coal tars 1, 2
• Coal tar solution (1% in hydrocortisone ointment) is generally preferred to crude coal tar 1, 2
• Topical calcineurin inhibitors (tacrolimus 0.1%, tacrolimus 0.03%, pimecrolimus 1%) are effective alternatives, particularly for facial eczema 6

Antihistamines

• Sedating antihistamines can be useful as a short-term adjuvant to topical treatment during relapses with severe pruritus, primarily for their sedative properties 1, 2
• Non-sedating antihistamines have little to no value in treating eczema 1, 2

Management of Secondary Infections

Bacterial Infections

• Treat overt secondary bacterial infections with appropriate antibiotics 1, 3
• Flucloxacillin is usually most appropriate for Staphylococcus aureus 1, 3
• Phenoxymethylpenicillin for β-hemolytic streptococci 1
• Erythromycin for penicillin-allergic patients 1, 3

Viral Infections

• For herpes simplex infection (eczema herpeticum), administer oral acyclovir early in the disease course 1, 3
• In ill, feverish patients, acyclovir should be given intravenously 1

Third-Line Treatment Options

Phototherapy

• Consider phototherapy for moderate to severe eczema not responding to first-line treatments 1, 6
• Narrowband UVB may be considered, showing a 75% reduction in mean severity scores with 17% clearance rate in some studies 3
• Oral PUVA therapy has shown significant improvement or clearance in 81-86% of patients with hand and foot eczema 3

Systemic Treatments

• Systemic corticosteroids have a limited but definite role in occasional patients with severe atopic eczema 1
• Should not be considered for maintenance treatment until all other avenues have been explored 1, 7

Prevention of Relapse

• Weekend (proactive) topical corticosteroid therapy significantly reduces the likelihood of relapse compared to no treatment (25% vs 58%) 4

Important Considerations and Precautions

Skin Thinning Risk

• Short-term use of topical corticosteroids (1-16 weeks) shows no significant evidence of increased skin thinning, even with potent formulations 6
• Longer-term use (6-60 months) may increase risk of skin thinning with mild to potent TCS 6
• Use topical corticosteroids cautiously on thin skin areas, particularly the face 1, 5

Systemic Absorption

• Systemic absorption of topical corticosteroids can produce hypothalamic-pituitary-adrenal (HPA) axis suppression 5
• Risk factors for systemic absorption include: application of potent steroids, use over large surface areas, prolonged use, and occlusive dressings 5
• Children may absorb proportionally larger amounts and be more susceptible to systemic toxicity 5

Special Populations

• In children, topical corticosteroids should be used cautiously due to risk of pituitary-adrenal axis suppression 2, 5
• For pregnant women, topical corticosteroids should be used only if the potential benefit justifies the potential risk to the fetus 5

When to Refer to a Specialist

• Consider referral if there is failure to respond to first-line treatment, extensive disease, or diagnostic uncertainty 1, 2