What are the recommended treatments for eczema care?

Recommended Treatments for Eczema Care

Topical corticosteroids are the mainstay of treatment for atopic eczema and should be your first-line therapy, using the least potent preparation that adequately controls the eczema. 1, 2

Core Treatment Algorithm

Step 1: Emollients as Foundation Therapy

• Apply emollients liberally and regularly as the cornerstone of all eczema management, even when the skin appears controlled 2
• Apply emollients immediately after bathing to provide a surface lipid film that prevents water loss from the epidermis 1, 2
• Use soap-free cleansers instead of regular soaps, as soaps and detergents strip natural lipids from already-dry eczematous skin 1, 2
• Avoid alcohol-containing lotions or gels; use oil-in-water creams or ointments instead 1, 2

Step 2: Topical Corticosteroid Selection by Potency

Use the least potent topical corticosteroid that controls symptoms, applying no more than twice daily 1, 2, 3

The evidence strongly supports this potency hierarchy:

• For mild eczema: Start with mild-potency topical corticosteroids (e.g., 1% hydrocortisone) 1, 4, 5
• For moderate eczema: Use moderate-potency topical corticosteroids, which achieve treatment success in 52% versus 34% with mild potency 3, 5
• For severe eczema: Use potent topical corticosteroids, which achieve treatment success in 70% versus 39% with mild potency 3, 5
• Very potent topical corticosteroids show uncertain additional benefit over potent preparations and should be reserved for the most severe, refractory cases 3, 5

Step 3: Application Frequency

Apply topical corticosteroids once daily rather than twice daily—both regimens have equivalent effectiveness 2, 3

• Once-daily application of potent topical corticosteroids does not decrease treatment success compared to twice-daily application (OR 0.97,95% CI 0.68 to 1.38) 3
• This approach reduces total steroid exposure without compromising efficacy 3

Step 4: Duration and Steroid Holidays

• Use potent and very potent corticosteroids with caution for limited periods only 1, 2
• Implement short "steroid holidays" when possible to minimize side effects, particularly pituitary-adrenal axis suppression in children 1, 2
• A 3-day burst of potent topical corticosteroid is as effective as 7 days of mild preparation for controlling flares 6

Managing Pruritus (Itching)

Use sedating antihistamines only as short-term adjuvants during severe pruritus episodes—their benefit comes from sedation, not direct anti-pruritic effects 1, 2

• Non-sedating antihistamines (cetirizine, loratadine, fexofenadine) have little to no value in atopic eczema and should not be used 1, 2
• Sedating antihistamines may lose effectiveness over time due to tachyphylaxis 1
• Urea- or polidocanol-containing lotions can help soothe pruritus 1

Managing Secondary Infections

Bacterial Infection

Watch for signs of bacterial superinfection: increased crusting, weeping, or pustules 1, 2

• Flucloxacillin is first-line for Staphylococcus aureus, the most common pathogen 1, 2
• Use phenoxymethylpenicillin if β-hemolytic streptococci are isolated 1, 2
• Use erythromycin for penicillin-allergic patients or flucloxacillin resistance 1, 2
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently 2

Viral Infection (Eczema Herpeticum)

If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum—this is a medical emergency 1, 7, 2

• For febrile patients with eczema herpeticum, administer intravenous acyclovir immediately 1, 7, 2
• For non-febrile patients, initiate oral acyclovir early in the disease course 1, 7, 2
• Deterioration in previously stable eczema may indicate secondary viral infection 1, 7

Proactive (Weekend) Therapy to Prevent Relapses

For patients with frequent flares, apply topical corticosteroids twice weekly (weekend therapy) to previously affected areas to prevent relapses 2, 3

• Weekend proactive therapy reduces relapse likelihood from 58% to 25% (RR 0.43,95% CI 0.32 to 0.57) 3
• This strategy is more effective than reactive application only during flares 3
• No evidence of abnormal skin thinning was found in trials lasting 16-20 weeks 3

Alternative Topical Agents

Coal Tar and Ichthammol

• Ichthammol (1% in zinc ointment) or coal tar solution (1% strength) can be used, particularly for lichenified eczema 1
• Ichthammol is less irritant than coal tar and may be applied as paste bandages 1
• Coal tar showed equal effectiveness to 1% hydrocortisone in one trial 8

Newer Agents (When Corticosteroids Are Insufficient)

Recent network meta-analyses rank effectiveness as follows 5:

• Ruxolitinib 1.5% (JAK inhibitor) and delgocitinib 0.5% show similar effectiveness to potent/very potent topical corticosteroids 5
• Tacrolimus 0.1% (topical calcineurin inhibitor) ranks among the most effective treatments, with similar efficacy to potent topical corticosteroids 5
• PDE-4 inhibitors (crisaborole 2%, roflumilast 0.15%) rank among the least effective treatments 5

Critical Safety Considerations

Local Adverse Events

Topical calcineurin inhibitors and crisaborole 2% cause more application-site reactions (burning, stinging) than topical corticosteroids 5

• Tacrolimus 0.1% (OR 2.2,95% CI 1.53 to 3.17) and crisaborole 2% (OR 2.12,95% CI 1.18 to 3.81) are most likely to cause site reactions 5
• Topical corticosteroids of all potencies are least likely to cause application-site reactions 5

Skin Thinning Risk

Short-term use (median 3 weeks) of topical corticosteroids, including very potent preparations, shows no evidence of increased skin thinning 3, 5

• Only 26 cases of abnormal skin thinning occurred among 2266 participants across 22 trials (1%) 3
• Most cases occurred with very potent (16 cases) or potent (6 cases) topical corticosteroids 3
• Longer-term use (6-60 months) does show increased skin thinning with mild to potent topical corticosteroids versus topical calcineurin inhibitors 3, 5
• Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is higher 2

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 2
• Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when possible 2
• Patients' or parents' fears of steroids often lead to undertreatment—explain the different potencies and the benefits/risks clearly 1, 2
• Do not prescribe non-sedating antihistamines for eczema—they provide no benefit 1, 2

When to Escalate or Refer

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks 2
• Need for systemic therapy (oral corticosteroids have a limited but definite role in severe atopic eczema) 2
• Need for phototherapy (narrow-band UVB at 312 nm is an option, though concerns exist about long-term skin aging and malignancy risk) 2
• Suspected eczema herpeticum (medical emergency requiring immediate intravenous acyclovir) 7, 2