What is the best oral treatment and prevention for eczema?

Best Oral Treatment and Prevention for Eczema

Oral antihistamines should be reserved for short-term nighttime use to manage severe pruritus during flares, with sedating antihistamines being the only effective option; oral corticosteroids should only be used as a last resort in severe cases that have failed all other treatments, and should never be used for maintenance therapy. 1

Oral Antihistamines for Symptom Management

Sedating Antihistamines (First-Line for Itch)

• Sedating antihistamines are the only oral antihistamines with proven value in eczema, working primarily through their sedative properties rather than histamine blockade 1, 2
• Use exclusively at nighttime to help patients sleep through severe pruritus episodes while avoiding daytime sedation 1, 2, 3
• Large doses may be required in children to achieve adequate symptom control 1, 3
• These should be used as short-term adjuvant therapy during relapses associated with severe pruritus, not as continuous treatment 1

Non-Sedating Antihistamines (Not Recommended)

• Non-sedating antihistamines have little or no value in atopic eczema and should not be used routinely 1, 2, 3
• High-quality Cochrane reviews found no consistent evidence that H1 antihistamines as add-on therapy provide meaningful benefit 4, 5
• While fexofenadine showed statistically significant reduction in pruritus, the clinical meaningfulness is questionable 5

Important Caveats

• Tachyphylaxis develops with prolonged use, progressively reducing antihistamine effectiveness 1, 3
• Hydroxyzine is contraindicated in early pregnancy 2, 3
• Antihistamines should never be used as monotherapy—no high-level evidence supports this approach 4

Oral Antibiotics for Secondary Infection

When to Use

• Oral antibiotics are important for treating overt secondary bacterial infection, indicated by crusting, weeping, or failure to respond to topical treatment 1
• Flucloxacillin is the first-line choice for Staphylococcus aureus (the most common pathogen) 1, 3
• Erythromycin for penicillin allergy or flucloxacillin resistance 1
• Phenoxymethylpenicillin if beta-hemolytic streptococci are isolated 1

Viral Infections

• Oral acyclovir should be given early for eczema herpeticum (indicated by grouped, punched-out erosions or vesiculation) 1, 3
• In ill, febrile patients, administer acyclovir intravenously 1, 3

Systemic Corticosteroids (Third-Line Only)

Critical Limitations

• Systemic corticosteroids have a limited but definite role only for occasional patients with severe atopic eczema 1, 2
• Should never be considered for maintenance treatment until all other avenues have been explored 1, 2
• The decision to use systemic steroids should never be taken lightly 1
• Try to avoid oral corticosteroids during acute crises 1
• Use of systemic corticosteroids is not generally recommended for chronic eczematous dermatitis 6

Why Avoid Systemic Steroids

• Risk of pituitary-adrenal axis suppression 1
• Possible interference with growth in children 1
• Should only be used to "tide over" severe flares, not for long-term control 1

Prevention Strategies (Non-Oral Approaches Are Primary)

Allergen and Irritant Avoidance

• Avoid soaps and detergents as they remove natural skin lipids—use dispersible cream as soap substitute 1
• Keep nails short to minimize scratching damage 1, 2
• Avoid irritant clothing (wool); wear cotton next to skin 1
• Avoid temperature extremes 1

Dietary Manipulation

• Evidence for dietary restriction is insufficient to make routine recommendations 1
• Consider dietary trial only when patient history strongly suggests specific food allergy or when widespread active eczema fails first-line treatment 1

Evening Primrose Oil

• No conclusions can be drawn from available data on evening primrose oil 1
• If tried, use adequate doses (160-320 mg daily in children 1-12 years; 320-480 mg in adults) for three months 1
• Discontinue if no benefit after three months 1

Treatment Algorithm

Most patients should be managed without oral medications:

1. First-line: Topical corticosteroids + emollients + avoidance of irritants 1, 2
2. For severe nighttime pruritus during flares: Add sedating antihistamines at bedtime only 1, 2, 3
3. For bacterial superinfection: Add oral flucloxacillin 1
4. For eczema herpeticum: Add oral acyclovir immediately 1
5. For severe refractory cases only: Consider short course of systemic corticosteroids after exhausting all other options 1, 2

The cornerstone of eczema management remains topical therapy, not oral medications 1, 2, 7