What are the treatment modalities for eczema?

Treatment Modalities for Eczema (Atopic Dermatitis)

Topical corticosteroids are the mainstay of treatment for atopic eczema and should be used as first-line therapy, combined with liberal emollient use as the cornerstone of maintenance therapy. 1, 2

First-Line Treatment: Topical Corticosteroids

Use the least potent topical corticosteroid preparation required to control the eczema, with short "steroid holidays" when possible. 1, 2

Potency Selection Based on Evidence:

• Moderate-potency topical corticosteroids achieve treatment success in 52% versus 34% with mild-potency (odds ratio 2.07), making them significantly more effective for moderate-to-severe eczema. 3

• Potent topical corticosteroids achieve treatment success in 70% versus 39% with mild-potency (odds ratio 3.71), representing a large increase in effectiveness. 3

• Potent versus moderate-potency shows insufficient evidence of additional benefit (odds ratio 1.33), so escalate to potent only if moderate fails. 3

• Very potent versus potent topical corticosteroids shows uncertain evidence with wide confidence intervals, so reserve very potent preparations for severe, refractory cases only. 3

Application Frequency:

• Apply topical corticosteroids once daily—this is equally effective as twice daily application for potent preparations (odds ratio 0.97). 2, 3

• Treatment should not be applied more than twice daily for any potency. 1

Critical Safety Considerations:

• Use very potent and potent corticosteroids with caution for limited periods only. 1, 2

• Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is higher. 2

• Abnormal skin thinning occurs in only 1% of cases (26 cases from 2266 participants), with most cases from higher-potency preparations (16 with very potent, 6 with potent). 3

• Address patient and parent fears about steroids directly—explain different potencies and benefits/risks clearly, as fear leads to undertreatment. 1, 2

Essential Adjunctive Therapy: Emollients

Liberal use of emollients is the cornerstone of maintenance therapy and must be applied regularly, even when eczema appears controlled. 2

• Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss from the epidermis. 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 recommended—patients should decide on the most suitable bath oil and bathing regimen. 1

• If using moisturizers with topical corticosteroids, apply emollients after the corticosteroid. 2

• In one observational study, regular emollient use reduced topical corticosteroid application rates by 62% and allowed 56% of patients to omit corticosteroids entirely. 4

Proactive (Weekend) Therapy to Prevent Flare-Ups

Weekend (proactive) therapy with topical corticosteroids applied twice weekly to previously affected areas results in a large decrease in relapse likelihood from 58% to 25% (risk ratio 0.43). 3

• Use this strategy for moderate-to-severe eczema lasting 16-20 weeks, with breaks between treatment periods. 2, 3

• No cases of abnormal skin thinning were identified in seven trials assessing this approach (1050 participants). 3

• Stop topical corticosteroids when signs and symptoms (itching, rash, redness) resolve, or as directed. 2

Managing Pruritus

Use sedating antihistamines for nighttime itching—their therapeutic value resides principally in their sedative properties, not direct anti-pruritic effects. 1, 2

• Sedating antihistamines should be used as short-term adjuvant to topical treatment during relapses with severe pruritus. 1

• Non-sedating antihistamines have little to no value in atopic eczema and should not be used. 1, 2

• Large doses of antihistamines may be required in children, with daytime use avoided. 1

• Antihistamine value may progressively reduce due to tachyphylaxis. 1

Managing Secondary Bacterial Infection

Watch for increased crusting, weeping, or pustules indicating secondary bacterial infection. 2

• Flucloxacillin is first-line oral antibiotic for Staphylococcus aureus, the most common pathogen. 1, 2

• Phenoxymethylpenicillin should be given if β-hemolytic streptococci are isolated. 1

• Erythromycin may be used when there is resistance to flucloxacillin or in penicillin-allergic patients. 1

• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not delay or withhold corticosteroids. 2

Managing Eczema Herpeticum (Medical Emergency)

If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum—this is a medical emergency. 2, 5

• Initiate oral acyclovir early in the disease course. 1, 2, 5

• In ill, feverish patients, administer acyclovir intravenously immediately. 1, 2, 5

Alternative Topical Anti-Inflammatory Agents

Topical Calcineurin Inhibitors (Pimecrolimus):

• Use pimecrolimus (Elidel) only after other prescription medicines have not worked or if your doctor recommends other prescription medicines should not be used. 6

• Do not use on children under 2 years of age. 6

• Use only on areas with eczema for short periods, with treatment repeated with breaks in between. 6

• Stop when signs and symptoms resolve. 6

• The safety of long-term use is not known—a very small number of users have had cancer (skin or lymphoma), though a link has not been shown. 6

• Do not use continuously for long periods. 6

Tar Preparations:

• Ichthammol (1% in zinc ointment) or paste bandages are particularly useful for healing lichenified eczema. 1

• Coal tar solution (1% strength) is generally preferred to crude coal tar and does not cause systemic side effects unless used extravagantly. 1

Third-Line Treatment for Severe Disease

Phototherapy:

• Narrow band ultraviolet B (312 nm) is an option for phototherapy. 1

• Some concern exists about long-term adverse effects such as premature skin aging and cutaneous malignancies, particularly with PUVA. 1

Systemic Corticosteroids:

• Systemic corticosteroids have a limited but definite role in tiding occasional patients with severe atopic eczema. 1

• Never take this decision lightly—systemic steroids should not be considered for maintenance treatment until all other avenues have been explored. 1

• Particularly important to avoid oral corticosteroids during crises. 1

Avoidance Measures

• Avoid soaps and detergents that remove natural lipid from skin surface—use dispersible cream as soap substitute. 1

• Avoid extremes of temperature. 1

• Keep nails short. 1

• Avoid irritant clothing such as woolens next to skin—cotton clothing is more comfortable and recommended. 1

• Do not use sun lamps, tanning beds, or ultraviolet light therapy during topical corticosteroid treatment. 2

• Limit sun exposure even when medicine is not on skin—wear loose fitting protective clothing if outdoors after applying treatment. 2

When to Refer to Specialist

• Failure to respond to treatment. 1

• Symptoms do not improve after 6 weeks of treatment. 2

• Failure to respond to moderate potency topical corticosteroids after 4 weeks. 2

• Need for systemic therapy or phototherapy. 2

• Suspected eczema herpeticum (medical emergency). 2