What is the best treatment for widespread scabbing from atopic dermatitis (eczema)?

Treatment of Widespread Scabbing from Eczema

For widespread scabbing from atopic dermatitis, initiate treatment with topical corticosteroids as the mainstay therapy, combined with aggressive emollient use and evaluation for secondary bacterial infection. 1

Initial Assessment

Before starting treatment, examine the patient for signs of infection, as widespread scabbing often indicates complications 1:

• Bacterial infection: Look for crusting, weeping, or honey-colored exudate suggesting Staphylococcus aureus infection 1
• Viral infection: Check for grouped, punched-out erosions or vesiculation indicating herpes simplex (eczema herpeticum) 1
• Severity assessment: Document the extent and distribution of scabbing to guide potency selection 1

First-Line Treatment Strategy

Topical Corticosteroids

Topical corticosteroids are the mainstay of treatment and should be selected based on severity 1:

• For widespread severe scabbing: Start with potent topical corticosteroids (e.g., betamethasone valerate 0.1%) applied once daily 2, 3
• For moderate scabbing: Use moderate-potency topical corticosteroids (e.g., prednicarbate 0.02%) 1, 2
• Application frequency: Once daily application is as effective as twice daily for potent corticosteroids 3
• Duration: Apply for 2-4 weeks maximum for high-potency preparations to minimize adverse effects 4

The evidence shows potent topical corticosteroids result in 70% treatment success versus 39% with mild preparations (OR 3.71,95% CI 2.04 to 6.72) 2.

Emollient Therapy

Liberal emollient use is essential and should be applied after bathing when skin is still hydrated 1:

• Apply emollients at least once daily to the entire body, not just affected areas 1, 5
• Use oil-in-water creams or ointments rather than alcohol-containing lotions 1, 4
• Apply emollients after topical corticosteroids, not before 1

Skin Care Modifications

Avoid factors that worsen dry skin and promote healing 1:

• Use dispersible cream as soap substitute instead of regular soap 1
• Avoid hot showers and excessive bathing 1, 4
• Keep nails short to minimize trauma from scratching 1
• Wear cotton clothing next to skin, avoid wool 1

Management of Secondary Infection

If crusting or weeping suggests bacterial infection, add systemic antibiotics 1:

• First choice: Flucloxacillin for Staphylococcus aureus (most common pathogen) 1, 4
• Penicillin allergy: Use erythromycin 1
• Duration: Treat for at least 2 weeks 1

If grouped erosions or vesicles suggest eczema herpeticum, start oral acyclovir immediately 1:

• Give early in disease course 1
• Use intravenous acyclovir if patient is febrile or systemically unwell 1

Adjunctive Treatments

For Severe Pruritus

Sedating antihistamines provide short-term relief primarily through sedative effects 1:

• Use only during severe flares with significant pruritus 1
• Give at nighttime to help with sleep disturbance 1
• Non-sedating antihistamines have little value in atopic eczema 1

For Lichenified (Thickened) Scabbed Areas

Ichthammol paste bandages can be particularly useful for healing lichenified eczema with scabbing 1:

• Apply 1% ichthammol in zinc ointment 1
• Less irritant than coal tar preparations 1

Reassessment and Next Steps

Evaluate response after 2 weeks 4:

• If improved: Step down to moderate-potency corticosteroid and continue emollients 4
• If no improvement: Consider secondary infection, add antibiotics, or refer to dermatology 1, 4
• If worsening: Rule out viral infection or contact dermatitis 1

Alternative Agents for Steroid-Sparing

For patients requiring long-term control or at risk of steroid atrophy, consider topical calcineurin inhibitors 4, 6:

• Tacrolimus 0.1% or pimecrolimus 1% can be used as maintenance therapy 4, 6, 5
• Apply to previously affected areas to prevent relapse 4
• Warning: May cause burning sensation initially, especially tacrolimus 6, 2
• Use only after age 2 years 6

Important Safety Considerations

Monitor for corticosteroid adverse effects, particularly with prolonged use 1:

• Risk of hypothalamic-pituitary-adrenal axis suppression, especially in children 1
• Skin atrophy risk increases with potency and duration 4, 3
• Use potent/very potent preparations for limited periods only (2-4 weeks maximum) 1, 4
• Avoid occlusive dressings unless specifically indicated 6

Do not use topical corticosteroids if active viral infection (eczema herpeticum) is suspected 1.