What are the treatment options for eczema?

Treatment of Eczema

Topical corticosteroids are the mainstay of treatment for eczema and should be used as first-line therapy, applying the least potent preparation required to control symptoms no more than twice daily. 1

First-Line Treatment Approach

Emollients and Skin Hydration

• Apply emollients immediately after bathing to provide a surface lipid film that retards evaporative water loss from the epidermis 1
• Use bathing for both cleansing and hydrating the skin, allowing patients to select the most suitable bath oil and regimen 1
• Replace regular soaps with dispersible cream as a soap substitute, since soaps and detergents remove natural lipids that are already deficient in eczema patients 1

Topical Corticosteroids (TCS)

• Start with the least potent preparation that effectively controls the eczema, escalating potency only as needed 1, 2
• Apply topical corticosteroids once daily rather than twice daily, as once-daily application is equally effective 3
• Use potent or very potent TCS for limited periods only, with intermittent breaks when possible to minimize risk of pituitary-adrenal axis suppression and growth interference in children 1, 2
• For maintenance therapy after achieving control, consider proactive intermittent application (twice weekly) of medium to high potency TCS to prevent flares 2, 4

Network meta-analysis evidence shows: Potent TCS, very potent TCS, and tacrolimus 0.1% rank among the most effective treatments for patient-reported symptoms, clinician-reported signs, and investigator global assessment 5

Avoidance of Triggers

• Keep nails short to minimize trauma and secondary infection risk 1, 2
• Avoid extremes of temperature 1, 2
• Avoid irritant clothing such as wool next to the skin; recommend cotton clothing instead 1

Second-Line Treatment Options

Topical Calcineurin Inhibitors (TCI)

• Use tacrolimus 0.1% ointment or pimecrolimus 1% for sensitive areas where prolonged steroid use raises concerns (face, eyelids, intertriginous areas) 2, 5
• Apply once daily to affected areas as a steroid-sparing agent 2
• Expect application-site reactions (burning, stinging) more commonly than with TCS, particularly with tacrolimus 0.1% (OR 2.2) and pimecrolimus 1% (OR 1.44) 5
• Network meta-analysis confirms tacrolimus 0.1% has similar effectiveness to potent TCS for clinician-reported signs and investigator global assessment 5

PDE-4 Inhibitors

• Crisaborole 2% and roflumilast 0.15% are available but rank among the least effective treatments in network meta-analysis 5
• Crisaborole 2% causes application-site reactions (OR 2.12) at rates similar to tacrolimus 5

JAK Inhibitors

• Ruxolitinib 1.5% and delgocitinib 0.5% rank among the most effective treatments, with effectiveness similar to potent/very potent TCS 5
• Ruxolitinib 1.5%: OR 9.34 for investigator global assessment success 5
• Delgocitinib 0.5%: OR 10.08 for investigator global assessment success 5

Management of Secondary Infections

Bacterial Infection

• Treat overt secondary bacterial infection with flucloxacillin as first-line antibiotic for Staphylococcus aureus, the most common pathogen 1, 2
• Use phenoxymethylpenicillin if β-hemolytic streptococci are isolated 1
• Use erythromycin for flucloxacillin resistance or penicillin allergy 1, 2
• Do not use routine prophylactic oral or topical antistaphylococcal treatments for infected eczema, as evidence does not support this practice 3
• Bacteriological swabs are not routinely indicated but obtain them if patients fail to respond to treatment 1

Viral Infection (Eczema Herpeticum)

• Administer oral acyclovir early in the course of eczema herpeticum 1, 2
• Use intravenous acyclovir for ill, febrile patients 1

Adjunctive Treatments

Antihistamines

• Use sedating antihistamines only as short-term adjuvants during severe pruritus relapses, primarily for their sedative properties at nighttime 1
• Avoid daytime use 1
• Large doses may be required in children 1
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used 1, 3
• Effectiveness may progressively decrease due to tachyphylaxis 1

Tar Preparations

• Consider ichthammol (1% in zinc ointment) or coal tar solution (1% strength) for lichenified eczema 1, 2
• Ichthammol is less irritant than coal tar and can be applied as paste bandages for healing lichenified areas 1

Third-Line Treatment for Severe, Refractory Disease

Systemic Immunosuppressants

• Cyclosporine is recommended as the first-choice systemic agent for severe atopic eczema refractory to conventional treatment, with 11 studies consistently showing effectiveness 6
• Consider azathioprine or interferon-γ as alternatives, both supported by randomized controlled trial evidence 6
• Systemic corticosteroids have a limited but definite role for occasional patients with severe atopic eczema but should never be used for maintenance treatment 1
• The decision to use systemic steroids should not be taken lightly and only after all other avenues have been explored 1
• Avoid systemic corticosteroids for chronic eczematous dermatitis as they are not generally recommended 7

Phototherapy

• Oral PUVA shows significant improvement or clearance in 81-86% of patients with hand and foot eczema and is superior to UVB in controlled studies 2
• Narrowband UVB (312 nm) may be considered, showing 75% reduction in mean severity scores with 17% clearance rate 2
• Long-term concerns exist about premature skin aging and cutaneous malignancies, particularly with PUVA 1

Treatments NOT Recommended

• Do not use intravenous immunoglobulins or infliximab based on published data 6
• Do not use probiotics for treating eczema, as evidence does not support their use 3
• Do not recommend silk clothing, ion-exchange water softeners, or emollient bath additives, as they have not been shown to benefit eczema patients 3
• Do not recommend emollients from birth for eczema prevention, as large trials show no benefit and potential harms including increased skin infections and food allergy 3

Important Safety Considerations

Topical Corticosteroid Risks

• Short-term use (median 3 weeks, range 1-16 weeks) shows no evidence of increased skin thinning with mild, moderate, potent, or very potent TCS 5
• Longer-term use (6-60 months) increases risk of skin thinning compared to topical calcineurin inhibitors 5
• Risk of pituitary-adrenal axis suppression exists, particularly with potent and very potent preparations used extensively or for prolonged periods 1, 2
• No evidence of increased pigmentation changes with short-term TCS use 5

Application Technique

• Demonstrate proper application technique through a practice or clinic nurse 1
• Provide written information to reinforce education 1
• Adequate time for explanation and discussion is essential for treatment adherence 1

Referral Criteria

• Refer to a specialist when patients fail to respond to first-line management 1
• Most patients with eczema respond well to first-line management and do not require specialist referral 1