What is the recommended treatment for eczema using steroid cream?

Steroid Cream Treatment for Eczema

Topical corticosteroids are the mainstay of treatment for eczema and should be used at the lowest effective potency to control symptoms, with short breaks when possible to minimize side effects. 1

Selecting the Right Topical Corticosteroid

• Use the least potent preparation required to keep the eczema under control 1
• For mild eczema, start with mild-potency topical corticosteroids 2
• For moderate to severe eczema, moderate-potency topical corticosteroids probably result in more treatment success than mild-potency ones (52% vs 34%) 3
• Potent topical corticosteroids probably result in a large increase in treatment success compared to mild-potency ones (70% vs 39%) 3
• For facial and periocular eczema, use low-potency topical corticosteroids due to the thin skin in these areas 4
• Very potent and potent categories should be used with caution for limited periods only 1

Application Method and Frequency

• Apply topical corticosteroids after bathing when skin is slightly damp for better absorption 4
• Apply a thin layer to affected areas only 2
• Once-daily application of potent topical corticosteroids is as effective as twice-daily application 3
• Do not apply more frequently than recommended as this doesn't improve efficacy but increases risk of side effects 5, 2

Duration of Treatment

• Use topical corticosteroids for short courses to control flares 5, 4
• When possible, topical corticosteroids should be stopped for short periods 1
• For maintenance therapy, weekend (proactive) application of topical corticosteroids reduces the likelihood of relapse from 58% to 25% compared to no treatment 3

Potential Side Effects and Monitoring

• The main risk is suppression of the pituitary-adrenal axis with possible interference of growth in children 1
• Abnormal skin thinning occurs in approximately 1% of patients, with higher risk when using higher-potency corticosteroids 3
• Monitor for signs of skin atrophy, telangiectasia, or striae 5, 4
• Risk of side effects increases with potency, duration of use, and application to thin skin areas 3

Adjunctive Therapies

• Emollients provide a surface lipid film which retards evaporative water loss from the epidermis 1
• Apply emollients after bathing for maximum effectiveness 1
• Use a dispersible cream as a soap substitute to cleanse the skin 1
• For severe pruritus, sedating antihistamines are useful as a short-term adjuvant during relapses 1, 2
• Non-sedating antihistamines have little or no value in atopic eczema 1, 2

Managing Secondary Infection

• Bacterial infection is suggested by crusting or weeping 1
• Flucloxacillin is usually the most appropriate antibiotic for treating S. aureus, the commonest pathogen 1
• For herpes simplex infection (suggested by grouped, punched-out erosions), acyclovir should be given early 1

Treatment-Resistant Cases

• Failure to respond to treatment is an indication for referral to a hospital specialist 1
• Recent evidence suggests that Janus kinase inhibitors (ruxolitinib, delgocitinib) and tacrolimus 0.1% rank among the most effective topical treatments alongside potent topical steroids 6
• Coal tar preparations may be as effective as 1% hydrocortisone for mild to moderate atopic eczema 7

Practical Tips

• Keep nails short to minimize damage from scratching 1
• Avoid irritant clothing such as woollens; cotton clothing is more comfortable 1
• Avoid extremes of temperature 1
• Avoid soaps and detergents as they remove natural lipids from the skin surface 1