What are the management strategies for eczema (atopic dermatitis) versus lichen simplex chronicus?

Management of Eczema vs Lichen Simplex Chronicus

The management of eczema (atopic dermatitis) and lichen simplex chronicus (LSC) differs primarily in that eczema requires a focus on inflammation control with topical corticosteroids as first-line therapy, while LSC treatment must prioritize breaking the itch-scratch cycle and addressing the underlying trigger factors. 1, 2, 3

Eczema (Atopic Dermatitis) Management

First-Line Treatment

• Topical corticosteroids are the mainstay of treatment for atopic eczema, using the least potent preparation required to control symptoms 1, 2
• Moderate to potent topical corticosteroids are more effective than mild preparations for moderate to severe eczema 4
• Once-daily application of potent topical corticosteroids is equally effective as twice-daily application 2, 4
• Regular bathing with emollients applied immediately after bathing provides a surface lipid film that retards evaporative water loss 1, 2
• Use dispersible creams as soap substitutes instead of regular soaps that remove natural skin lipids 2
• Avoid extreme temperatures and irritant clothing (wool); cotton clothing is preferred 1, 2
• Keep nails short to minimize damage from scratching 1, 2

Management of Secondary Infections

• Treat overt bacterial infections with appropriate antibiotics: flucloxacillin for Staphylococcus aureus, phenoxymethylpenicillin for β-hemolytic streptococci, and erythromycin for penicillin-allergic patients 1, 2
• For herpes simplex infection (eczema herpeticum), administer oral acyclovir early in the disease course; use intravenous acyclovir for ill, feverish patients 1, 2

Second-Line Treatment Options

• Ichthammol (1% in zinc ointment) is useful for lichenified eczema 1, 2
• Coal tar solution (1% in hydrocortisone ointment) can be effective and does not cause systemic side effects unless used excessively 1, 2
• Sedating antihistamines are useful as short-term adjuvants during severe pruritus flares, primarily for their sedative properties 1, 5
• Non-sedating antihistamines have little to no value in atopic eczema 1, 5

Third-Line Treatment Options

• Consider phototherapy for moderate to severe eczema not responding to first-line treatments 2
• Systemic corticosteroids have a limited role in severe cases but should not be used for maintenance therapy 1, 2
• Weekend (proactive) topical corticosteroid therapy significantly reduces relapse rates compared to reactive treatment 4

Lichen Simplex Chronicus Management

First-Line Treatment

• High-potency topical corticosteroids to break the itch-scratch cycle and reduce inflammation 3, 6
• Paste bandages containing ichthammol (1% in zinc ointment) are particularly useful for healing lichenified areas 1
• Identify and address underlying triggers including psychological distress, heat, sweating, and excess dryness 3, 6
• Rule out and treat other conditions that may trigger LSC such as candidiasis, psoriasis, lichen sclerosus, tinea cruris, and neoplasia 6
• Sedating antihistamines can help control nighttime itching and improve sleep 1, 3

Second-Line Treatment Options

• Intralesional corticosteroid injections for thick, persistent plaques 3
• Occlusive dressings to prevent scratching and enhance topical medication penetration 6
• Consider oral alitretinoin (30 mg daily) which has shown efficacy in reducing pruritus and improving clinical appearance of LSC 7
• Address any underlying sensory neuropathy or chronic conditions like scabies that may contribute to persistent scratching 8

Key Differences in Management Approach

• Focus: Eczema management focuses on controlling inflammation and maintaining skin hydration, while LSC management prioritizes breaking the itch-scratch cycle 3, 6
• Occlusion: Occlusive dressings are more commonly used in LSC to prevent scratching and enhance medication penetration 1, 6
• Psychological factors: Addressing psychological distress is particularly important in LSC management 3, 6
• Underlying conditions: LSC requires thorough investigation for underlying conditions that may trigger scratching behavior 6, 8

Common Pitfalls and Caveats

• Undertreatment: Fear of topical corticosteroids often leads to undertreatment of both conditions; proper education about safe use is essential 1, 4
• Skin thinning: Risk of skin thinning increases with higher potency corticosteroids but overall incidence is low (1% in clinical trials) when used appropriately 4
• Treatment duration: No clear evidence exists on optimal duration of treatment for flares, but limiting potent corticosteroids to short periods is recommended 1, 4
• Maintenance therapy: For eczema, weekend (proactive) application of topical corticosteroids reduces relapse rates compared to reactive treatment 4
• Chronic nature: Both conditions tend to be chronic and may require long-term management strategies 3, 6