What is the treatment for eczema?

Treatment of Eczema

Topical corticosteroids are the mainstay of treatment for eczema, with the basic principle being to use the least potent preparation required to keep the eczema under control. 1

First-Line Treatment: Topical Corticosteroids

• Start with mild-potency topical corticosteroids for mild eczema, applying a thin layer to affected areas only. 2

• For moderate to severe eczema, use moderate to potent topical corticosteroids. 3, 4 Potent topical corticosteroids result in a large increase in treatment success compared to mild-potency preparations (70% versus 39% achieving clearance or marked improvement). 3

• Apply topical corticosteroids once daily rather than twice daily—both frequencies show similar effectiveness. 3 More frequent application does not improve efficacy but increases the risk of side effects. 2

• Apply topical corticosteroids for short periods and stop when signs and symptoms (itching, rash, redness) resolve. 2 When possible, corticosteroids should be stopped for short periods. 1

• The risk of skin thinning with short-term use (median 3 weeks) is very low across all potencies. 4 However, longer-term use (6-60 months) does increase skin thinning risk. 4

Emollients and Skin Care

• Use emollients regularly and liberally as they provide a surface lipid film which retards evaporative water loss. 2

• Apply emollients after topical corticosteroids, not before. 2

• Avoid soap and detergents as they remove natural lipids from the skin surface. 2 Use soap-free cleansers instead. 5

• Apply treatment after bathing when skin is dry. 1

Management of Pruritus (Itching)

• Use sedating antihistamines (such as hydroxyzine) primarily at night for severe pruritus during flare-ups. 1, 2 Their therapeutic value resides principally in their sedative properties. 1

• Do not use non-sedating antihistamines—they have little to no value in controlling itch in atopic eczema. 1, 2

• Avoid daytime use of sedating antihistamines. 1 Large doses may be required in children. 1

• Keep nails short to minimize damage from scratching. 2

Second-Line Treatments: Topical Calcineurin Inhibitors

• Pimecrolimus 1% cream and tacrolimus ointment (0.03% or 0.1%) can be used in conjunction with topical corticosteroids as first-line treatment. 5

• Tacrolimus 0.1% is more effective than pimecrolimus 1%, with patients almost twice as likely to improve. 6

• Tacrolimus 0.1% is superior to low-potency topical corticosteroids but shows equivocal results compared to moderate-to-potent corticosteroids. 6

• Expect application-site reactions (burning, stinging) with topical calcineurin inhibitors—these are usually mild, occur during the first 5 days, and typically clear within a few days. 7, 6, 4 Tacrolimus and pimecrolimus are ranked most likely to cause local application-site reactions. 4

• Do not use topical calcineurin inhibitors continuously for long periods or on children under 2 years old. 7 Use only on areas with active eczema. 7

• Avoid sun exposure, tanning beds, and ultraviolet light therapy during treatment with topical calcineurin inhibitors. 7

Proactive (Weekend) Therapy to Prevent Flare-ups

• Apply topical corticosteroids twice weekly (weekend therapy) to previously affected areas to prevent relapse. 2 This reduces the likelihood of relapse from 58% to 25%. 3

• This proactive approach is more effective than reactive application (treating only when flares occur). 3

Treatment of Secondary Infections

• For bacterial superinfection with Staphylococcus aureus, use flucloxacillin as first-line antibiotic. 1

• Use erythromycin when there is resistance to flucloxacillin or in patients with penicillin allergy. 1

• For β-hemolytic streptococci, give phenoxymethylpenicillin. 1

• For eczema herpeticum (herpes simplex infection) with fever, administer intravenous acyclovir immediately. 1, 8 Give the drug early in the course of disease. 1

• For eczema herpeticum without systemic illness, use oral acyclovir. 1

Adjunctive Treatments

• Ichthammol or coal tar preparations can be useful for lichenified (thickened) eczema. 1 Ichthammol 1% in zinc ointment or paste bandages are particularly effective. 1

• Coal tar solution 1% is generally preferred to crude coal tar and does not cause systemic side effects unless used extravagantly. 1

Third-Line Treatment: Systemic Corticosteroids

• Systemic corticosteroids have a limited but definite role for occasional patients with severe atopic eczema. 1, 2

• Do not use systemic steroids for maintenance treatment until all other avenues have been explored. 1, 2

• Try to avoid oral corticosteroids during acute crises. 1

Newer Treatments

• Crisaborole 2% (PDE-4 inhibitor) and dupilumab (biologic) are effective but currently cost-prohibitive for most patients. 5

• JAK inhibitors (such as ruxolitinib 1.5% and delgocitinib 0.5%) rank among the most effective treatments in network meta-analyses. 4

When to Refer to a Specialist

• Refer to a dermatologist when first-line management fails to control symptoms. 1

• Maximum waiting time for first appointment should be six weeks. 1

Important Caveats

• Very potent and potent topical corticosteroids should be used with caution for limited periods only due to risk of pituitary-adrenal axis suppression, particularly in children. 1

• Do not cover treated skin with bandages, dressings, or wraps—normal clothing is acceptable. 7

• Hydroxyzine is contraindicated during early pregnancy. 2

• The value of antihistamines may be progressively reduced due to tachyphylaxis (tolerance). 1