What are the treatment options for eczema?

Treatment Options for Eczema

Topical corticosteroids are the mainstay of treatment for eczema and can be used safely with appropriate precautions, using the least potent preparation required to control symptoms. 1

First-Line Treatment Approach

Avoidance of Provoking Factors

• Avoid soaps and detergents that remove natural skin lipids; use a dispersible cream as a soap substitute instead 1
• Keep nails short to minimize trauma and secondary infection risk 1
• Avoid irritant clothing such as wool; cotton clothing is recommended 1
• Avoid extremes of temperature that can worsen symptoms 1

Emollients and Bathing

• Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss 1
• Bathing is useful for both cleansing and hydrating the skin; patients should determine the most suitable bath oil and regimen 1

Topical Corticosteroids

• Use the least potent preparation required to keep eczema under control 1
• Apply no more than twice daily; some newer preparations require only once daily application 1
• When possible, corticosteroids should be stopped for short periods to minimize side effects 1
• Potent and very potent categories should be used with caution and for limited periods only due to risk of pituitary-adrenal axis suppression 1

Second-Line Treatment Options

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% and pimecrolimus 1% are effective alternatives to topical corticosteroids, particularly for sensitive areas 2, 3
• Pimecrolimus is indicated for patients age 2 years and older who do not have a weakened immune system 4
• These agents should not be used continuously for a long time due to potential safety concerns 4

Ichthammol and Tar Preparations

• Ichthammol (1% in zinc ointment) or in paste bandages is useful for healing lichenified eczema 1
• Coal tar solution (1% in hydrocortisone ointment) is generally preferred to crude coal tar 1

Antihistamines

• Sedating antihistamines are useful as short-term adjuvants during relapses with severe pruritus 1
• Non-sedating antihistamines have little or no value in atopic eczema 1
• Antihistamines should be used while asleep; daytime use should be avoided 1

Management of Secondary Infections

• Antibiotics are important for treating overt secondary bacterial infection 1
• Flucloxacillin is usually most appropriate for Staphylococcus aureus, the commonest pathogen 1
• Erythromycin may be used when there is resistance to flucloxacillin or in patients with penicillin allergy 1
• Eczema herpeticum (herpes simplex infection) responds to oral acyclovir, which should be given early in the course of disease 1

Third-Line and Refractory Disease Treatment

Phototherapy

• Narrow band ultraviolet B (312 nm) may be considered for refractory cases 1, 2
• PUVA therapy has shown significant improvement in hand and foot eczema 2
• Concerns exist about long-term adverse effects such as premature skin aging and cutaneous malignancies 1

Systemic Treatments

• Systemic corticosteroids have a limited but definite role in severe atopic eczema 1
• The decision to use systemic steroids should never be taken lightly and should not be considered for maintenance treatment 1
• Cyclosporine is recommended as first option for patients with atopic eczema refractory to conventional treatment 5
• Evidence also exists for azathioprine for severe cases 5, 6
• Newer biologics like dupilumab show effectiveness for moderate to severe eczema 6

Important Caveats and Pitfalls

• Undertreatment of eczema is common due to fear of topical steroids; proper education about safe use is essential 1, 7
• Bacteriological swabs are not routinely indicated but may be necessary if patients do not respond to treatment 1
• While short-term use of topical corticosteroids shows no evidence of increased skin thinning, longer-term use may increase this risk 3
• Topical calcineurin inhibitors and crisaborole are more likely to cause application site reactions than topical corticosteroids 3
• There is little evidence to support the use of oral antihistamines, oral or topical antistaphylococcal treatments for infected eczema, or probiotics 7

Treatment Algorithm Based on Severity

Mild Eczema

• Emollients and avoidance of triggers 1
• Mild topical corticosteroids as needed 1

Moderate Eczema

• Moderate potency topical corticosteroids 1, 2
• Consider topical calcineurin inhibitors for steroid-sparing effect 2, 4
• Antihistamines for severe pruritus 1

Severe Eczema

• Potent/very potent topical corticosteroids for short periods 1, 3
• Referral to specialist if not responding to first-line management 1
• Consider systemic treatments (cyclosporine, azathioprine, dupilumab) 5, 6