What are the treatment options for an eczema flare, including oral steroids and antibiotics?

Treatment of Eczema Flares: Oral Steroids and Antibiotics

Oral steroids should generally be avoided for eczema flares and reserved only for severe acute exacerbations requiring short-term use (<7 days), while antibiotics should be used only when overt secondary bacterial infection is present—not for routine eczema flares. 1

Oral Corticosteroids: Limited Role with Significant Caveats

When to Consider (Rarely)

• Low-dose, short-term oral corticosteroids (<7 days) may be considered only for severe acute exacerbations of eczema that have failed all other treatments. 1
• The Taiwan Academy of Pediatric Allergy guidelines specifically state that routine use of systemic corticosteroids is "generally discouraged" and should be reserved only for special circumstances. 1
• The American Academy of Dermatology emphasizes that systemic corticosteroids have a "limited but definite role" and the decision should "never be taken lightly." 1

Critical Warnings About Oral Steroids

• Rebound flares are common upon discontinuation of oral corticosteroids. 1
• Long-term use is not recommended due to well-known adverse effects including pituitary-adrenal axis suppression and growth interference in children. 1
• Recent evidence shows that even short-term use of oral corticosteroids is associated with a small but significantly increased risk of severe adverse events in both children and adults. 1
• Oral steroids should not be considered for maintenance treatment until all other avenues have been explored. 1

FDA-Approved Indications

Prednisolone is FDA-approved for atopic dermatitis as part of its dermatologic disease indications, but this approval does not negate the guideline recommendations for cautious, limited use. 2

Antibiotics: Only for Confirmed Infection

When Antibiotics Are Indicated

• Antibiotics are important for treating overt secondary bacterial infection in eczema patients, not for routine flares. 1
• Clinical signs suggesting true bacterial infection include: painful skin lesions, pustules on arms/legs/trunk, yellow crusts, discharge, or failure to respond to standard topical therapy. 1
• Staphylococcus aureus is the most common pathogen in infected eczema. 1

Antibiotic Selection

• Flucloxacillin is the most appropriate first-line antibiotic for S. aureus infection. 1
• Phenoxymethylpenicillin should be given if β-hemolytic streptococci are isolated. 1
• Erythromycin may be used when there is resistance to flucloxacillin or in patients with penicillin allergy. 1
• Treatment duration should be at least 14 days when infection is confirmed. 1

Evidence Against Routine Antibiotic Use

A 2017 pragmatic randomized controlled trial found that children with clinically infected eczema showed rapid resolution with topical steroids and emollients alone, with no clinically meaningful benefit from adding either oral or topical antibiotics. 3 This high-quality study enrolled 113 children with clinical signs of infection (93% had weeping, crusting, pustules, or painful skin) and found mean POEM scores improved from 13.4-16.9 at baseline to 6.2-9.3 at 2 weeks across all groups, with no significant differences between antibiotic and control groups. 3

Caution with Topical Antibiotics

While topical antibiotic/corticosteroid combinations may improve disease severity short-term, a 2012 study found that fucidin-resistant S. aureus increased from 8% to 58% after just two weeks of treatment. 4 This raises concerns about promoting antibiotic resistance with empirical use.

Recommended Treatment Algorithm for Eczema Flares

First-Line Treatment (Majority of Flares)

• Topical corticosteroids (potent or moderate potency) applied once daily, plus emollients at least twice daily. 1, 5
• Potent topical corticosteroids are probably more effective than mild preparations for moderate to severe eczema. 5
• Once daily application is as effective as twice daily for potent topical corticosteroids. 5
• Continue for 2-3 weeks maximum, then reassess. 6, 7

Second-Line Options (If First-Line Inadequate)

• Add topical calcineurin inhibitors (tacrolimus 0.1%) or consider phototherapy. 1
• For children ≥6 years with moderate to severe eczema inadequately controlled by topical therapy, dupilumab is an evidence-based option. 1

Third-Line (Severe, Refractory Cases Only)

• Consider immunomodulators (cyclosporine, methotrexate, azathioprine) before resorting to oral corticosteroids. 1
• If oral corticosteroids are absolutely necessary: use the lowest effective dose for <7 days only. 1

Special Considerations

Viral Infections

• Eczema herpeticum requires oral acyclovir given early in the disease course; use IV acyclovir in ill, febrile patients. 1
• This is a true indication for systemic antimicrobial therapy in eczema. 1

Prevention of Flares

• Weekend (proactive) therapy with topical corticosteroids probably results in a large decrease in relapse likelihood from 58% to 25%. 5
• This approach involves applying topical corticosteroids twice weekly to previously affected areas even when clear. 5

Common Pitfalls to Avoid

• Do not prescribe oral antibiotics empirically for eczema flares without clear signs of bacterial infection. The 2017 RCT definitively showed no benefit in mild clinically infected eczema. 3
• Do not use oral corticosteroids as a quick fix for flares. The rebound phenomenon and adverse effects outweigh short-term benefits. 1
• Do not continue topical corticosteroids beyond 2-3 weeks without reassessment. 6, 7
• Do not assume all weeping, crusting eczema requires antibiotics. These signs improved equally well with topical steroids alone in the 2017 trial. 3