What are the treatment options for atopic dermatitis (eczema)?

Treatment Options for Atopic Dermatitis (Eczema)

The mainstay treatment for atopic dermatitis consists of emollients for daily maintenance and topical corticosteroids for flare-ups, with additional targeted therapies based on severity and location of the condition. 1

First-Line Treatment Approach

Skin Hydration and Protection

• Use emollients liberally and frequently to maintain skin hydration and improve barrier function 1
• Apply emollients immediately after bathing for maximum effectiveness 2
• Replace regular soaps with dispersible cream soap substitutes to prevent removal of natural skin lipids 2
• Wear cotton clothing and avoid irritant materials like wool directly against the skin 2
• Keep nails short to minimize damage from scratching 2

Topical Anti-inflammatory Therapy

• Use topical corticosteroids as the primary treatment for flare-ups 2
• Select the least potent preparation required to control symptoms 2
• Apply topical corticosteroids once or twice daily until the flare resolves 2
• For facial eczema, use mild-potency corticosteroids (such as 1% hydrocortisone) due to the thinner skin in this area 1
• Consider topical calcineurin inhibitors (like pimecrolimus) for sensitive areas or as steroid-sparing agents, especially for patients 2 years and older 3

Proactive Maintenance Therapy

• After clearing a flare, consider a proactive approach using topical anti-inflammatories 2-3 times weekly on previously affected areas to prevent recurrence 1, 4
• This proactive approach has been shown to reduce flare frequency and extend remission periods 4, 5
• Both topical corticosteroids and calcineurin inhibitors can be effective when used in this manner 1

Managing Pruritus and Sleep Disturbance

• Sedating antihistamines may be helpful as short-term adjuncts during severe itching episodes, primarily due to their sedative properties 2
• Non-sedating antihistamines have little to no value in controlling atopic dermatitis symptoms 2, 6
• Antihistamine effectiveness may diminish over time due to tachyphylaxis 2

Alternative Topical Treatments

• Ichthammol (1% in zinc ointment) or coal tar preparations may be considered for lichenified eczema 2
• Coal tar solution is generally preferred to crude coal tar and can be used in a 1% strength with hydrocortisone ointment 2
• These preparations do not cause systemic side effects unless used excessively 2

Managing Secondary Infections

• Monitor for signs of secondary bacterial infection (crusting, weeping) 2
• For bacterial infections, flucloxacillin is usually most appropriate for Staphylococcus aureus (the most common pathogen) 2
• Use phenoxymethylpenicillin for beta-hemolytic streptococci infections 2
• Consider erythromycin for penicillin-allergic patients or when resistance to flucloxacillin is present 2
• For herpes simplex infections (presenting as grouped, punched-out erosions or vesicles), use oral acyclovir early in the course of disease 2

When to Consider Referral to a Specialist

• When there is diagnostic uncertainty 1
• When first-line treatments fail to control symptoms 1
• When considering second-line treatments 1
• For severe or widespread disease that may require systemic therapy 2

Important Precautions

• For patients using pimecrolimus (Elidel), avoid continuous long-term use due to potential safety concerns 3
• Apply pimecrolimus only to affected areas with eczema 3
• Do not use pimecrolimus in children under 2 years of age 3
• Resolve bacterial or viral infections at treatment sites before starting pimecrolimus 3
• Minimize sun exposure during treatment with pimecrolimus and avoid tanning beds or ultraviolet light therapy 3