What are the treatment options for eczema (atopic dermatitis)?

Treatment of Eczema (Atopic Dermatitis)

Topical corticosteroids are the mainstay of treatment for eczema and should be used as first-line therapy, with the basic principle of using the least potent preparation required to keep the eczema under control. 1

First-Line Treatment Strategy

Topical Corticosteroids

• Apply topical corticosteroids no more than twice daily (some newer preparations require only once daily application) to affected areas, using the least potent preparation that controls symptoms 1
• For moderate flare-ups, potent corticosteroids (such as 0.1% triamcinolone acetonide or 0.1% betamethasone valerate) are significantly more effective than mild corticosteroids and should be considered for faster disease control 2, 3
• Very potent and potent corticosteroids should be used with caution for limited periods only, with short "steroid holidays" when possible to minimize side effects 1
• Short-term use (median 3 weeks) of topical corticosteroids does not increase risk of skin thinning, though longer-term use (6-60 months) may cause skin atrophy 2, 4
• Intermittent use of mild to moderate potency topical corticosteroids for up to 5 years shows little to no difference in growth abnormalities, infections, or malignancies in children 4

Essential Adjunctive Measures

• Liberal use of emollients is the cornerstone of maintenance therapy and should be applied regularly, even when eczema appears controlled 5
• Apply emollients after bathing to provide a surface lipid film that retards water loss 1, 6
• Use soap-free cleansers and avoid alcohol-containing products 5
• Regular bathing for cleansing and hydrating the skin is recommended 6

Second-Line Treatment Options

Topical Calcineurin Inhibitors

• Pimecrolimus 1% cream and tacrolimus ointment (0.03% or 0.1%) can be used in conjunction with topical corticosteroids as first-line treatment, particularly for sensitive areas like the face 7, 8
• Tacrolimus 0.1% is ranked among the most effective treatments, comparable to potent corticosteroids 2
• Pimecrolimus 1% is significantly less effective than moderate/potent corticosteroids and 0.1% tacrolimus, but may have a role in long-term maintenance therapy 2, 3
• These agents cause more application-site reactions (burning, stinging) than corticosteroids, typically occurring during the first few days and improving as lesions resolve 7, 2
• Use only for short periods with breaks in between; do not use continuously long-term due to uncertain long-term safety profile 7
• Do not use in children under 2 years of age 7
• Avoid sun exposure and do not use with UV light therapy while using these medications 7

Newer Topical Agents

• Ruxolitinib 1.5% (JAK inhibitor) is ranked among the most effective treatments, comparable to potent corticosteroids and tacrolimus 0.1% 2
• Delgocitinib 0.5% and 0.25% (JAK inhibitors) show high effectiveness comparable to very potent corticosteroids 2
• Crisaborole 2% (PDE-4 inhibitor) is ranked among the least effective topical treatments and causes significant application-site reactions 2, 8
• Roflumilast 0.15% and other PDE-4 inhibitors are consistently ranked among the least effective options 2

Managing Pruritus

• Sedating antihistamines (such as diphenhydramine) may help with nighttime itching through their sedative properties, not through direct anti-pruritic effects 1, 5, 6
• Use at night while asleep; avoid daytime use 1
• Large doses may be required in children 1
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used 1, 6, 8
• The value of antihistamines may be progressively reduced due to tachyphylaxis 1

Managing Secondary Infections

Bacterial Infections

• Watch for signs of secondary bacterial infection: increased crusting, weeping, or pustules 5, 6
• Flucloxacillin is the first-line oral antibiotic for Staphylococcus aureus, the most common pathogen 1, 5, 6
• Use erythromycin when there is resistance to flucloxacillin or in patients with penicillin allergy 1, 6
• Phenoxymethylpenicillin should be given if beta-hemolytic streptococci are isolated 1
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently 6

Viral Infections (Eczema Herpeticum)

• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum - this is a medical emergency 1, 5, 6
• Initiate oral acyclovir early in the disease course 1, 6
• In ill, feverish patients, administer acyclovir intravenously 1, 5, 6

Systemic Therapy for Moderate-to-Severe Disease

Dupilumab (Biologic)

• Dupilumab is FDA-approved for moderate-to-severe atopic dermatitis in patients aged 6 months and older whose disease is not adequately controlled with topical therapies or when those therapies are not advisable 9
• Can be used with or without topical corticosteroids 9
• Complete age-appropriate vaccinations prior to initiating treatment 9
• Administered by subcutaneous injection 9

Phototherapy

• Ultraviolet phototherapy is safe and effective for moderate to severe atopic dermatitis when first-line treatments are inadequate 8
• Narrow band ultraviolet B (312 nm) has been introduced as an option 1
• Some concern exists about long-term adverse effects such as premature skin aging and cutaneous malignancies, particularly with PUVA 1

Systemic Corticosteroids

• Have a limited but definite role in tiding occasional patients with severe atopic eczema 1

Common Pitfalls to Avoid

• Do not delay or withhold topical corticosteroids when infection is present - they remain the primary treatment when appropriate systemic antibiotics are given 6
• Do not use topical corticosteroids continuously without breaks - implement "steroid holidays" when possible 1
• Avoid very potent corticosteroids in thin-skinned areas (face, neck, flexures, genitals) where risk of atrophy is higher 5
• Do not cover treated skin with bandages, dressings, or wraps unless specifically indicated (such as paste bandages for lichenified eczema) 1, 7
• Patients' or parents' fears of steroids often lead to undertreatment - explain the different potencies and the benefits/risks clearly 1

When to Refer or Escalate

• Failure to respond to moderate potency topical corticosteroids after 4 weeks 5
• Need for systemic therapy or phototherapy 5
• Suspected eczema herpeticum (medical emergency) 5
• Development of lymphadenopathy without clear infectious etiology 7