What is the best ointment for treating eczema?

Best Ointment for Eczema

Topical corticosteroid ointments 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

Potency Selection Based on Severity

• For mild to moderate eczema: Start with hydrocortisone 1% (mild potency) applied twice daily 1
• For moderate eczema not responding to mild corticosteroids: Use clobetasone butyrate 0.05% (Eumovate) or betamethasone valerate 0.025% (Betnovate-RD) (moderate potency) 1
• For severe eczema or lichenified areas: Use betamethasone valerate 0.1% (Betnovate) or mometasone 0.1% (Elocon) (potent corticosteroids) 1, 2
• For very severe, resistant eczema: Consider clobetasol propionate 0.05% (Dermovate) (very potent), but use with extreme caution and for limited periods only 1

Evidence Supporting Potency Choices

• Moderate-potency corticosteroids result in significantly more participants achieving treatment success compared to mild preparations (52% versus 34%) 2
• Potent corticosteroids produce even better results compared to mild preparations (70% versus 39% achieving treatment success) 2
• However, there is insufficient evidence that very potent corticosteroids offer advantages over potent preparations 2
• A short 3-day burst of potent corticosteroid (0.1% betamethasone valerate) is equally effective as 7 days of mild preparation (1% hydrocortisone) for mild to moderate eczema in children 3

Application Frequency

Apply topical corticosteroids once daily rather than twice daily - this is equally effective for potent corticosteroids and reduces the risk of adverse effects 1, 2. The evidence shows no difference in treatment success between once daily versus twice daily application (moderate-certainty evidence) 2.

Ointment Versus Cream Formulation

Use ointments rather than creams when the skin is dry, as ointments provide better occlusion and moisture retention 1. Creams should be reserved for weeping or acutely inflamed areas 1.

Essential Adjunctive Treatment: Emollients

Emollients must be used liberally alongside corticosteroids - they provide a surface lipid film that retards evaporative water loss from the epidermis and are most effective when applied after bathing 1. Apply emollients AFTER topical corticosteroids, not before 4.

Recommended Emollient Quantities

• Face and neck: 15-30 g per 2 weeks
• Both hands: 15-30 g per 2 weeks
• Both arms: 30-60 g per 2 weeks
• Both legs: 100 g per 2 weeks
• Trunk: 100 g per 2 weeks 1

Maintenance Strategy: Proactive Weekend Therapy

After achieving control, apply potent corticosteroids twice weekly (weekend therapy) to previously affected areas to prevent flare-ups rather than waiting for flares to occur 2. This proactive approach reduces the likelihood of relapse from 58% to 25% (moderate-certainty evidence) 2.

Second-Line Options

When Corticosteroids Are Insufficient or Inappropriate

Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) can be used for:

• Facial eczema where corticosteroid side effects are concerning 5
• Maintenance therapy in patients requiring frequent corticosteroid use 5

Important caveats for calcineurin inhibitors:

• Do NOT use in children under 2 years old 5
• Use only for short periods with breaks in between 5
• Apply only to areas with active eczema 5
• Stop when symptoms resolve 5
• Less effective than moderate/potent corticosteroids and should not be first-line 6

Tar Preparations

Ichthammol 1% in zinc ointment is particularly useful for healing lichenified (thickened) eczema and is less irritant than coal tar 1, 7. Coal tar solution 1% can be used but is generally less preferred 1.

Critical Safety Considerations

Corticosteroid Side Effects

• Skin thinning risk is low with appropriate use - only 26 cases of abnormal skin thinning were identified among 2266 participants across 22 trials (1%) 2
• Risk increases with higher potency preparations (16 cases with very potent, 6 with potent, 2 with moderate, 2 with mild) 2
• In children, adrenal suppression is the main concern with very potent and potent preparations used extensively 1, 8
• Medium-strength corticosteroids (like 0.1% triamcinolone) used for up to 6 weeks show no notable adrenal suppression in children with severe eczema 8

When to Stop and Reassess

• Stop corticosteroids when signs and symptoms (itching, rash, redness) resolve 5
• If no improvement after 6 weeks, reconsider the diagnosis 5
• If worsening occurs, consider secondary bacterial or viral infection 1

Common Pitfalls to Avoid

• Undertreatment due to steroid phobia - this is extremely common and leads to poor control 1
• Using creams on dry skin instead of ointments 1
• Applying emollients before rather than after corticosteroids 4
• Not using emollients liberally enough (should use 200-400 g per week for whole body) 1
• Continuing to use soap instead of soap substitutes (dispersible creams or emollient washes) 1, 4
• Bathing immediately after applying corticosteroids, which washes off the medication 5