What is the typical treatment for eczema?

Treatment of Eczema (Atopic Dermatitis)

Start with topical corticosteroids as first-line therapy, using the least potent preparation that controls symptoms, combined with liberal emollient use—this remains the cornerstone of eczema management. 1

First-Line Treatment Algorithm

Topical Corticosteroids

• Apply topical corticosteroids no more than twice daily to affected areas, using the least potent preparation required to maintain control 2, 1
• For mild-to-moderate eczema, start with hydrocortisone 1-2.5% (mild potency) 3
• For moderate-to-severe eczema, use moderate or potent topical corticosteroids 4, 5
• Potent and moderate topical corticosteroids are significantly more effective than mild topical corticosteroids for moderate or severe eczema (OR 3.71 for potent vs mild; OR 2.07 for moderate vs mild) 4, 5
• Once-daily application of potent topical corticosteroids is as effective as twice-daily application (OR 0.97,95% CI 0.68 to 1.38), so once daily is sufficient 5
• Very potent and potent corticosteroids should be used with caution for limited periods only, with short "steroid holidays" when possible 2, 1
• Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is higher 1, 3

Essential Emollient Therapy

• Liberal use of emollients is the cornerstone of maintenance therapy and should be applied regularly, even when eczema appears controlled 1, 6
• Apply emollients after bathing to provide a surface lipid film that retards water loss 1
• Use soap-free cleansers and avoid alcohol-containing products 1, 3

Managing Pruritus (Itching)

• Use sedating antihistamines (e.g., diphenhydramine) at nighttime only for severe pruritus—they work through sedative properties, not direct anti-pruritic effects 2, 1, 3
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used 2, 1
• Daytime use of sedating antihistamines should be avoided 2
• Large doses may be required in children 2

Managing Secondary Infections

Bacterial Infection

• Watch for signs of secondary bacterial infection: increased crusting, weeping, or pustules 1, 3
• Flucloxacillin is first-line oral antibiotic for Staphylococcus aureus, the most common pathogen 2, 1, 3
• Use erythromycin in penicillin-allergic patients 2
• Use phenoxymethylpenicillin if β-hemolytic streptococci are isolated 2
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not withhold anti-inflammatory treatment 1

Eczema Herpeticum (Medical Emergency)

• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum 1, 3, 7
• Initiate oral acyclovir early in the disease course 2, 1, 7
• In ill, feverish patients, administer intravenous acyclovir immediately—this is a medical emergency 1, 7

Proactive (Weekend) Therapy to Prevent Flare-Ups

• For patients with frequent relapses, apply topical corticosteroids twice weekly (weekend therapy) to previously affected areas even when skin appears clear 5
• Weekend proactive therapy reduces relapse risk from 58% to 25% (RR 0.43,95% CI 0.32 to 0.57) compared to reactive use only 5

Second-Line Treatments for Refractory Disease

• Narrow band ultraviolet B (312 nm) phototherapy is an option for moderate-to-severe disease 2, 1
• Some concern exists about long-term adverse effects such as premature skin aging and cutaneous malignancies, particularly with PUVA 2, 1
• Systemic corticosteroids have a limited but definite role in tiding occasional patients with severe atopic eczema, but should not be considered for maintenance treatment until all other avenues have been explored 2, 1

Safety Profile of Topical Corticosteroids

• Short-term use (median 3 weeks) of topical corticosteroids does not increase skin thinning risk, even with very potent preparations 5
• Abnormal skin thinning occurred in only 1% of participants across trials (26 cases from 2266 participants), mostly with higher-potency preparations 5
• Longer-term use (6-60 months) showed increased skin thinning with mild to potent topical corticosteroids versus topical calcineurin inhibitors (6 events in 2044 participants, 0.3%) 4, 5
• Topical calcineurin inhibitors (tacrolimus 0.1%, pimecrolimus 1%) and crisaborole 2% cause more application-site reactions than topical corticosteroids 4, 8

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 1
• Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when possible 2, 1
• Patients' or parents' fears of steroids often lead to undertreatment—explain the different potencies and the benefits/risks clearly 2, 1
• Do not apply topical corticosteroids more than twice daily—once daily is sufficient for potent preparations 2, 1, 5

When to Refer to Specialist

• Failure to respond to moderate potency topical corticosteroids after 4 weeks 1, 3
• Need for systemic therapy or phototherapy 1, 3
• Suspected eczema herpeticum (medical emergency requiring immediate treatment) 1, 3