What are the treatment options for eczema?

Treatment of Eczema (Atopic Dermatitis)

Topical corticosteroids are the mainstay of treatment for eczema and should be your first-line therapy, using the least potent preparation that controls symptoms, applied no more than twice daily. 1, 2

First-Line Treatment Approach

Topical Corticosteroids - The Foundation

• Apply topical corticosteroids once daily (not twice daily) to affected areas - recent evidence shows once-daily application is as effective as twice-daily with potentially fewer side effects 3
• Use the least potent preparation required to achieve control, then implement "steroid holidays" (short breaks) when possible to minimize adverse effects 1, 2
• Potent corticosteroids rank among the most effective treatments alongside JAK inhibitors and tacrolimus 0.1%, significantly outperforming PDE-4 inhibitors and mild corticosteroids 4
• Very potent and potent corticosteroids should be reserved for limited periods only, particularly avoiding use on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is higher 1, 2

Essential Adjunctive Therapy

• Liberal emollient use is the cornerstone of maintenance therapy - apply regularly even when eczema appears controlled, most effectively after bathing to create a surface lipid film that retards water loss 1, 2
• Use soap-free cleansers (dispersible cream as soap substitute) and avoid alcohol-containing products 1, 2
• Regular bathing for cleansing and hydrating the skin is beneficial 1, 2
• Avoid irritants: extremes of temperature, woolen clothing next to skin (cotton preferred), and keep nails short 1

Managing Pruritus

• Use sedating antihistamines only for nighttime itching - their value lies in sedative properties, not direct anti-pruritic effects; use at night only, avoid daytime use 1, 2
• Do not use non-sedating antihistamines - they have little to no value in atopic eczema 1, 2, 3
• Large doses may be required in children 1

Managing Secondary Infections

Bacterial Infection

• Watch for increased crusting, weeping, or pustules indicating secondary bacterial infection 1, 2
• Flucloxacillin is first-line for Staphylococcus aureus (the most common pathogen); use phenoxymethylpenicillin for β-hemolytic streptococci, or erythromycin for penicillin allergy/resistance 1, 2
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently - do not delay or withhold steroids 2
• Do not use oral or topical antistaphylococcal treatments for infected eczema - evidence does not support their routine use 3

Viral Infection (Eczema Herpeticum)

• Suspect eczema herpeticum if you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever - this is a medical emergency 1, 2
• Initiate oral acyclovir early in the disease course 1, 2
• In ill, feverish patients, administer acyclovir intravenously 1, 2

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% ranks among the most effective treatments (comparable to potent corticosteroids) and is particularly useful for sensitive sites like face and neck 2, 4
• Tacrolimus 0.03% and pimecrolimus 1% are less effective options 4
• Expect application-site reactions - tacrolimus 0.1%, tacrolimus 0.03%, and pimecrolimus 1% are most likely to cause local burning/stinging compared to corticosteroids 4

Moderate-to-Severe Disease Requiring Systemic Therapy

Biological Therapy - First Choice for Systemic Treatment

• Dupilumab is the most effective biological treatment for moderate-to-severe eczema 5, 6
• Dupilumab achieves EASI75 (75% improvement in Eczema Area and Severity Index) significantly better than placebo (RR 3.04,95% CI 2.51-3.69) with high-certainty evidence 6
• Dupilumab improves POEM scores (mean difference 7.30,95% CI 6.61-8.00) at short-term follow-up 6
• Dupilumab has favorable short-term safety with lower proportion of serious adverse events compared to placebo, though it is associated with specific adverse events including eye inflammation and eosinophilia 5, 6
• Approved for adults and children ≥6 months with moderate-to-severe atopic dermatitis not controlled with topical therapies 5

Conventional Systemic Immunosuppressants

• Cyclosporine is recommended as first-line conventional systemic option for patients refractory to topical treatment, with consistent evidence of effectiveness across 11 studies 7
• Evidence also exists for interferon-γ and azathioprine from randomized controlled trials 7
• Systemic corticosteroids have a limited but definite role for occasional patients with severe atopic eczema, but should never be considered for maintenance treatment until all other avenues are explored 1
• Mycophenolate mofetil showed effectiveness in small uncontrolled studies 7

Phototherapy

• Narrow band ultraviolet B (312 nm) is an option for phototherapy 1
• Concern exists about long-term adverse effects including premature skin aging and cutaneous malignancies, particularly with PUVA 1

Treatments to Avoid

Ineffective or Unproven Therapies

• Do not use probiotics for treating eczema - evidence does not support their use 3
• Do not recommend silk clothing, ion-exchange water softeners, or emollient bath additives - large trials have not shown benefit 3
• Do not recommend emollients from birth for eczema prevention - despite promising pilot studies, large trials show they do not prevent eczema and may increase skin infections and food allergy 3
• Evening primrose oil has mixed evidence; if tried, use adequate doses (160-320 mg daily in children 1-12 years, 320-480 mg in adults) for 3 months, but discontinue if no benefit 1

Treatments Lacking Adequate Evidence

• Dietary manipulation may be indicated only when patient history strongly suggests specific food allergy or when widespread active eczema is not responding to first-line treatment 1
• House dust mite eradication has weak evidence and no effective complete eradication measures currently exist 1

Common Pitfalls to Avoid

• Undertreatment due to steroid phobia - patients' or parents' fears of steroids often lead to inadequate treatment; explain different potencies and benefits/risks clearly 1, 2
• Applying treatments more than twice daily - once or twice daily application is sufficient 1
• Using very potent corticosteroids continuously without breaks - implement "steroid holidays" when possible 1, 2
• Delaying topical corticosteroids when infection is present - they remain primary treatment when appropriate systemic antibiotics are given concurrently 2

When to Refer to Specialist

• Failure to respond to moderate potency topical corticosteroids after 4 weeks 2
• Need for systemic therapy or phototherapy 2
• Suspected eczema herpeticum (medical emergency requiring immediate referral) 2
• Failure to respond to first-line management 1