What is the first line of treatment for eczema (atopic dermatitis)?

First-Line Treatment for Eczema (Atopic Dermatitis)

The first-line treatment for eczema consists of liberal and frequent application of emollients for daily maintenance combined with mild-potency topical corticosteroids (such as 1% hydrocortisone) applied to affected areas during flare-ups. 1, 2

Core Treatment Algorithm

Step 1: Emollient Therapy (Foundation of All Treatment)

• Apply emollients liberally and frequently to all affected skin to maintain hydration and improve barrier function 1, 2
• Apply emollients immediately after bathing when they are most effective at preventing dryness 1
• Replace regular soaps with soap substitutes (dispersable creams) to prevent removal of natural skin lipids and reduce irritation 1, 2
• Continue emollient use even when skin appears clear, as barrier dysfunction persists 3, 4

Step 2: Topical Corticosteroid Selection for Flares

The potency of topical corticosteroid should be matched to both the severity of eczema and the body site being treated:

• For mild eczema or facial/sensitive areas: Use mild-potency corticosteroids (1% hydrocortisone) 1, 2, 5
• For moderate eczema on the body: Use moderate-potency corticosteroids 3, 6
• For severe eczema on the body: Use potent corticosteroids 3, 6, 7

The fundamental principle is to use the least potent preparation required to control the eczema 8, 1

Step 3: Application Frequency and Duration

• Apply topical corticosteroids once daily during flares—this is as effective as twice-daily application for potent corticosteroids 6
• Apply for limited periods until the flare resolves, then stop 1, 2
• Treatment should not be applied more than 3-4 times daily per FDA labeling 5
• When possible, corticosteroids should be stopped for short periods 8

Evidence Supporting Treatment Choices

Comparative Effectiveness Data

Potent and moderate topical corticosteroids are significantly more effective than mild corticosteroids for moderate-to-severe eczema:

• Moderate-potency corticosteroids achieve treatment success in 52% versus 34% with mild-potency (OR 2.07) 6
• Potent corticosteroids achieve treatment success in 70% versus 39% with mild-potency (OR 3.71) 6
• Network meta-analysis ranked potent topical corticosteroids, tacrolimus 0.1%, and ruxolitinib 1.5% among the most effective treatments 3, 7

However, for facial atopic dermatitis and in infants, mild-potency corticosteroids (1% hydrocortisone) remain first-line due to the increased risk of side effects on thin facial skin 1, 2

Managing Pruritus During Flares

• Sedating antihistamines may be useful as short-term adjuvants during severe flares with significant itching, primarily due to their sedative properties 8, 1, 2
• Non-sedating antihistamines have little to no value in atopic eczema 8, 1
• Use antihistamines at bedtime to help with sleep disruption; avoid daytime use 8
• Large doses may be required in children 8

Addressing Secondary Bacterial Infection

Monitor for signs of secondary infection including crusting, weeping, and punched-out erosions:

• Flucloxacillin is the most appropriate antibiotic for treating Staphylococcus aureus, the most common pathogen 8, 1
• Phenoxymethylpenicillin should be given if β-hemolytic streptococci are isolated 8
• Erythromycin may be used with flucloxacillin resistance or penicillin allergy 8
• Eczema herpeticum (herpes simplex infection) requires prompt treatment with oral acyclovir; give intravenously in ill, feverish patients 8, 1

Safety Considerations

Short-Term Use (1-5 weeks)

• Abnormal skin thinning is rare with short-term use, occurring in only 1% of participants across trials 3, 6
• Risk increases with higher potency: 16 cases with very potent, 6 with potent, 2 with moderate, and 2 with mild corticosteroids 6
• No evidence of increased skin thinning with short-term use of any topical corticosteroid potency 3, 6

Longer-Term Use (6-60 months)

• Skin thinning occurred in 0.3% (6/2044) of participants with longer-term topical corticosteroid use 7
• Risk of pituitary-adrenal axis suppression exists, particularly with potent/very potent corticosteroids and in children 8

Special Populations

• Infants are particularly susceptible to side effects due to their high body surface area to volume ratio 1
• Use 1% hydrocortisone for infants and apply for limited periods only 1

Proactive Maintenance Therapy (After Initial Control)

Once eczema is controlled, consider proactive maintenance to prevent relapses:

• Apply topical corticosteroids 2-3 times weekly to previously affected areas 2
• This approach reduces relapse risk from 58% to 25% (RR 0.43) 6
• Weekend (proactive) therapy is significantly more effective than reactive use only 6

When to Refer to a Specialist

Refer to dermatology when:

• Failure to respond to first-line treatment 1, 2
• Diagnostic uncertainty 1, 2
• Second-line treatments are being considered 1, 2
• Maximum waiting time should be six weeks 8

Common Pitfalls to Avoid

• Do not use potent or very potent corticosteroids on the face or in infants without specialist guidance—the risk of side effects is significantly higher 1, 2
• Do not continue ineffective treatments—if no response after a reasonable trial, escalate or refer 8
• Do not prescribe non-sedating antihistamines for eczema—they have no therapeutic value 8, 1
• Do not apply corticosteroids more frequently than once daily for potent preparations—increased frequency does not improve efficacy 6
• Ensure patients understand that emollients are the foundation of treatment and must be continued even when skin appears clear 4