What is the best treatment for an eczema rash?

Treatment of Eczema Rash

For typical eczema, start with regular emollients applied at least once daily to the whole body, combined with topical corticosteroids—using potent or moderate-potency formulations for moderate-to-severe disease and mild potency for mild disease—applied once daily to affected areas for 2-4 weeks. 1, 2, 3

First-Line Treatment Approach

Emollients and Skin Care (Foundation of All Treatment)

• Apply emollients at least once daily to the entire body, not just affected areas, to restore moisture and provide a surface lipid film that prevents evaporative water loss 4, 2
• Avoid hot showers, excessive soap use, and all alcohol-containing lotions or gels, as these remove natural skin lipids and worsen dryness 4, 2
• Use dispersible cream as a soap substitute instead of traditional soaps and detergents 1, 2
• Apply emollients after bathing to maximize hydration 2
• Favor oil-in-water creams or ointments over lotions 4

Topical Corticosteroids (Primary Active Treatment)

For moderate-to-severe eczema:

• Use potent topical corticosteroids (such as betamethasone valerate 0.1% or mometasone furoate 0.1%) as first-line treatment, as they are significantly more effective than mild-potency corticosteroids, with 70% achieving treatment success versus 39% with mild corticosteroids 3
• Moderate-potency corticosteroids (such as hydrocortisone valerate 0.2% or prednicarbate 0.02%) are also effective, with 52% achieving success versus 34% with mild corticosteroids 3
• Apply once daily—this is equally effective as twice-daily application for potent corticosteroids 3
• Continue for 2-4 weeks initially, then reassess 4

For mild eczema:

• Start with mild-potency topical corticosteroids (such as hydrocortisone 1%) 5
• Apply to affected areas 3-4 times daily as needed 5

Important corticosteroid principles:

• Very potent corticosteroids show uncertain additional benefit over potent corticosteroids for short-term use 3
• Short-term use (median 3 weeks) does not cause skin thinning, even with very potent formulations 6, 7
• However, longer-term use (6-60 months) can cause skin thinning in approximately 0.3% of patients 7
• Avoid using topical corticosteroids continuously without breaks when possible 2

Second-Line and Adjunctive Treatments

For Inadequate Response to Topical Corticosteroids

Consider topical calcineurin inhibitors:

• Tacrolimus 0.1% is nearly as effective as potent topical corticosteroids and superior to mild corticosteroids, with people almost twice as likely to improve compared to pimecrolimus 1% 6, 7, 8
• Tacrolimus 0.03% is effective for facial and sensitive areas, superior to mild corticosteroids 8
• Main drawback: burning sensation at application site occurs in approximately 2-3 times more patients than with corticosteroids, but this is typically mild and transient, occurring mainly in the first few days 6, 8
• No risk of skin atrophy, making them particularly useful for face, neck, and intertriginous areas 8, 9
• Can be used as monotherapy or when corticosteroid side effects are a concern 9

JAK inhibitors (newer option):

• Ruxolitinib 1.5% and delgocitinib 0.25-0.5% rank among the most effective treatments, comparable to potent corticosteroids 6, 7

For Severe Pruritus During Flares

• Use sedating antihistamines (such as diphenhydramine or clemastine) exclusively at nighttime to help patients sleep through severe itching episodes 4, 1
• These work through sedative properties, not histamine blockade 1
• Use only as short-term adjuvant therapy during relapses, not continuously 1
• Large doses may be required in children 1
• Non-sedating antihistamines (cetirizine, loratadine, fexofenadine) have little to no value in eczema and should not be used routinely 4, 1
• Tachyphylaxis develops with prolonged antihistamine use 1

For Secondary Bacterial Infection

Recognize infection by:

• Crusting, weeping, or pustules 1
• Failure to respond to appropriate topical treatment 1

Treatment:

• Oral flucloxacillin is first-line for Staphylococcus aureus (the most common pathogen) 1, 2
• Erythromycin for penicillin allergy or flucloxacillin resistance 1, 2
• Phenoxymethylpenicillin if beta-hemolytic streptococci are isolated 1
• Take bacterial swabs before starting calculated antibiotic treatment 4

For Eczema Herpeticum (Herpes Simplex Superinfection)

• Recognize by grouped, punched-out erosions or vesiculation 1
• Start oral acyclovir immediately and early in the disease course 1, 2

Maintenance and Prevention of Flares

Proactive (Weekend) Therapy

• For patients with frequent relapses, apply topical corticosteroids twice weekly (e.g., weekends) to previously affected areas even when clear, which reduces relapse risk from 58% to 25% 3
• This approach is significantly more effective than reactive treatment (treating only when flares occur) 3
• Continue regular emollient use daily 3

Lifestyle Modifications

• Keep nails short to minimize scratching damage 1, 2
• Avoid wool clothing; wear cotton next to skin 1, 2
• Avoid temperature extremes 1, 2
• Dietary restriction has insufficient evidence for routine recommendation; consider trial only when patient history strongly suggests specific food allergy or when widespread active eczema fails first-line treatment 1

Third-Line Treatment (Severe Refractory Cases Only)

Systemic Corticosteroids

• Reserve for occasional patients with severe atopic eczema after all other options have been exhausted 1
• Never use for maintenance treatment 1
• Try to avoid even during acute crises 1
• Concerns include pituitary-adrenal axis suppression and possible growth interference in children 1
• Short-term oral systemic steroids are recommended only for grade 3 erythema and/or desquamation 4

Common Pitfalls to Avoid

• Do not use greasy creams for basic care, as they may facilitate folliculitis development due to occlusive properties 4
• Avoid topical acne medications (including retinoids), as they worsen eczema through drying and irritation 4
• Do not manipulate or pick at skin, which increases infection risk 4
• Avoid hot blow-drying of hair and wearing tight shoes 4
• Do not use topical corticosteroids inadequately, as this can cause perioral dermatitis and skin atrophy 4
• Most patients should be managed without oral medications, using topical treatments as the foundation 1