What are the treatment options for eczema?

Treatment of Eczema

First-Line Treatment: Topical Corticosteroids

Topical corticosteroids are the mainstay of treatment for eczema and should be used as first-line therapy, applying the least potent preparation that effectively controls symptoms. 1, 2, 3

Potency Selection Based on Severity

• For moderate to severe eczema: Use potent or moderate-potency topical corticosteroids, as they are significantly more effective than mild-potency preparations (70% vs 39% treatment success for potent vs mild; 52% vs 34% for moderate vs mild) 4, 5

• For mild eczema: Start with mild to moderate-potency topical corticosteroids 1, 3

• For facial eczema: Use mild to moderate-potency corticosteroids due to thinner skin and increased risk of side effects 3

• Very potent corticosteroids show uncertain benefit over potent preparations and should be reserved for severe, refractory cases 4, 5

Application Frequency and Duration

• Apply once daily for potent topical corticosteroids—this is equally effective as twice-daily application and reduces medication burden 4, 5

• Apply twice daily for mild to moderate-potency preparations 1, 2

• Stop treatment when signs and symptoms (itching, rash, redness) resolve, or use short breaks between treatment periods to minimize side effects 1, 6

• Treatment duration typically ranges from 1-5 weeks for acute flares 4

Safety Considerations

• Short-term use (median 3 weeks) shows no evidence of increased skin thinning across all potency levels 5

• Intermittent use up to 5 years probably results in little to no difference in growth abnormalities, skin atrophy, or systemic effects when used appropriately 7

• In children: Use cautiously due to potential pituitary-adrenal axis suppression, though this risk is low with appropriate intermittent use 1, 7

• Skin thinning risk increases with longer-term continuous use (6-60 months), particularly with potent preparations 5

Essential Skin Care Measures

Bathing and Emollients

• Bathe regularly for cleansing and hydrating the skin, allowing patients to choose their preferred bath oil and regimen 1, 2

• Apply emollients immediately after bathing while skin is still damp to provide a surface lipid film that retards water loss 1, 2, 3

• Use dispersible cream as a soap substitute instead of regular soaps and detergents that strip natural skin lipids 1, 2, 3

Avoidance Measures

• Avoid extreme temperatures and maintain comfortable environmental conditions 1, 2, 3

• Wear cotton clothing next to the skin and avoid irritant materials like wool 1, 2, 3

• Keep nails short to minimize damage from scratching and reduce infection risk 1, 2, 3

Second-Line Topical Treatments

Topical Calcineurin Inhibitors

• Pimecrolimus 1% (Elidel) and tacrolimus are effective alternatives when topical corticosteroids are inadequate or inappropriate 6, 8

• Use only in patients age 2 years and older with non-immunocompromised status 6

• Apply for short periods with breaks between treatments; do not use continuously long-term due to uncertain safety profile 6

• Most common side effect is burning or warmth at application site (usually mild to moderate, occurring in first 5 days and resolving within a week) 6

• Tacrolimus 0.1% ranks among the most effective treatments in network meta-analyses, comparable to potent topical corticosteroids 5

Coal Tar and Ichthammol

• Ichthammol 1% in zinc ointment is less irritant than coal tars and particularly useful for lichenified (thickened) eczema 1, 2, 3

• Coal tar solution 1% in hydrocortisone ointment is generally preferred to crude coal tar and does not cause systemic side effects unless used extravagantly 1, 2, 3

• Coal tar cream shows equal effectiveness to 1% hydrocortisone for mild to moderate eczema 9

Proactive (Maintenance) Therapy

Weekend (proactive) therapy with topical corticosteroids prevents relapses and should be used in patients with frequent flares. 2, 4

• Apply topical corticosteroids twice weekly (e.g., weekends) to previously affected areas after initial clearance 4

• This reduces relapse risk from 58% to 25% compared to reactive treatment only 4

• No increased skin thinning was observed in trials lasting up to 20 weeks with this approach 4

Management of Secondary Infections

Bacterial Infections

• Flucloxacillin is the first-choice antibiotic for Staphylococcus aureus, the most common pathogen 1, 2, 3

• Phenoxymethylpenicillin should be used if β-hemolytic streptococci are isolated 1, 2, 3

• Erythromycin is appropriate for penicillin allergy or flucloxacillin resistance 1, 2, 3

• Bacteriological swabs are not routinely indicated but necessary if patients fail to respond to treatment 1

Viral Infections

• Eczema herpeticum (herpes simplex infection) requires oral acyclovir started early in the disease course 1, 2, 3

• In ill, feverish patients, administer acyclovir intravenously 1, 3

Adjunctive Treatments

Antihistamines

• Sedating antihistamines are useful as short-term adjuvants during severe pruritic episodes, primarily for their sedative properties 1, 2, 3

• Non-sedating antihistamines have little to no value in treating eczema and should not be used 1, 2, 3, 8

• Avoid daytime use of sedating antihistamines; reserve for nighttime to aid sleep 2

• Effectiveness may decrease over time due to tachyphylaxis 1

Newer Topical Agents

JAK Inhibitors

• Ruxolitinib 1.5% and delgocitinib 0.5% rank among the most effective treatments in network meta-analyses, comparable to potent topical corticosteroids 5

PDE-4 Inhibitors

• Crisaborole 2% is FDA-approved but ranks among the least effective treatments in comparative studies 5, 8

• Application-site reactions are common (similar frequency to tacrolimus 0.1%) 5

• Cost is currently prohibitive for most patients 8

Application Technique

• Apply thin layer only to affected skin areas 1, 2, 6

• Wash hands before application and after (if not treating hands) to remove residual cream 6

• Ensure skin is dry after bathing before applying topical corticosteroids 6

• Apply emollients after topical corticosteroids, not before 4

• Do not cover with occlusive bandages unless specifically directed; normal clothing is acceptable 6

• Avoid bathing, showering, or swimming immediately after application to prevent washing off medication 6

Sun Protection During Treatment

• Limit sun exposure during treatment with topical calcineurin inhibitors 6

• Avoid sun lamps, tanning beds, and UV light therapy while using pimecrolimus or tacrolimus 6

• Wear loose-fitting protective clothing over treated areas when outdoors 6

When to Escalate or Refer

• Consider referral if there is failure to respond to first-line treatment after 6 weeks, extensive disease, or diagnostic uncertainty 2, 3, 6

• Phototherapy should be considered for moderate to severe eczema not responding to topical treatments 3, 8

• Systemic corticosteroids have a limited role only for severe cases after all other options are exhausted, and should not be used for maintenance 3

• Newer systemic agents like dupilumab are effective but currently cost-prohibitive 8

Common Pitfalls to Avoid

• Steroid phobia: Undertreatment due to fear of side effects is common; educate patients that appropriate intermittent use is safe 1, 7

• Using potency too low for severity: Mild corticosteroids are significantly less effective for moderate to severe eczema 4, 5

• Applying to eyes: Avoid ocular contact with all topical treatments 6

• Continuous long-term use: Use intermittent treatment with breaks rather than continuous application to minimize adverse effects 1, 6

• Ignoring deterioration: Worsening of previously stable eczema may indicate secondary infection or contact dermatitis requiring different management 1