What is the first line of treatment for eczema (atopic dermatitis)?

First-Line Treatment for Eczema (Atopic Dermatitis)

The first-line treatment for eczema consists of liberal and frequent application of emollients for daily maintenance combined with mild-potency topical corticosteroids (such as 1% hydrocortisone) applied to affected areas during flare-ups. 1, 2

Core Treatment Algorithm

Daily Maintenance Therapy

• Apply emollients liberally and frequently to maintain skin hydration and improve barrier function—this is the foundation of all eczema management 1, 2
• Emollients work most effectively when applied immediately after bathing to lock in moisture and prevent dryness 1, 2
• Replace all regular soaps with soap substitutes (dispersable creams) because standard soaps and detergents strip away natural skin lipids and worsen the condition 1
• Bathing is beneficial for cleansing and hydrating the skin, contrary to older beliefs that it should be avoided 1

Flare-Up Management

• Apply mild-potency topical corticosteroids (1% hydrocortisone) to affected areas during active flares 3, 1, 2, 4
• Use the least potent preparation required to control the eczema—this minimizes side effects while maintaining efficacy 3, 1
• Apply topical corticosteroids no more than 3-4 times daily, though twice daily is typically sufficient 3, 4
• Continue treatment for short periods only until the flare resolves, then stop 3, 1

Proactive Maintenance for Recurrent Disease

• Apply topical anti-inflammatories (corticosteroids or calcineurin inhibitors) 2-3 times weekly to previously affected areas even when clear to reduce flare frequency and lengthen time to relapse 1
• This proactive approach is particularly valuable for patients with moderate disease who experience frequent relapses 1

Special Considerations by Body Site

Facial Eczema

• The face requires extra caution because facial skin is thinner and more susceptible to steroid-related side effects (skin atrophy, telangiectasia) 1
• Stick with mild-potency corticosteroids (1% hydrocortisone) for facial application 1
• Consider topical calcineurin inhibitors as an alternative for sensitive facial areas where prolonged steroid use poses risks 1

Infants and Young Children

• Infants are particularly vulnerable to systemic absorption of topical corticosteroids due to their high body surface area to volume ratio 2
• Use 1% hydrocortisone for flares and apply for limited periods only 2
• Emollient therapy is especially critical in this age group 2

Adjunctive Treatments During Flares

Managing Pruritus

• Sedating antihistamines may be useful as short-term adjuvants during severe flares with significant itching, primarily due to their sedative properties rather than antihistamine effects 3, 1, 2
• Use at nighttime to help with sleep disruption from scratching 3
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used 3, 1, 2
• Large doses may be required in children to achieve sedative effect 3

Alternative Topical Agents

• Ichthammol (1% in zinc ointment) may be considered as a less irritant alternative topical treatment, particularly for lichenified eczema 3, 1

Managing Secondary Complications

Bacterial Infections

• Monitor for signs of secondary bacterial infection: crusting, weeping, or punched-out erosions 1, 2
• Flucloxacillin is the most appropriate antibiotic for Staphylococcus aureus, the most common pathogen 3, 2
• Use phenoxymethylpenicillin if beta-hemolytic streptococci are isolated 3
• Erythromycin is appropriate for penicillin-allergic patients or flucloxacillin-resistant organisms 3

Viral Infections

• Watch for eczema herpeticum (herpes simplex superinfection): grouped, punched-out erosions or vesicles 1, 2
• Treat with oral acyclovir early in the disease course 3, 2
• Use intravenous acyclovir for ill, feverish patients 3

Common Pitfalls and Caveats

• Do not use potent or very potent topical corticosteroids as first-line treatment—these should be reserved for specialist use and limited periods only 3
• The main risk with topical corticosteroids is pituitary-adrenal axis suppression with possible growth interference in children, particularly with overuse of potent preparations 3
• Avoid continuous long-term use of topical corticosteroids; incorporate steroid-free periods when possible 3
• Do not apply treatments more than twice daily—more frequent application does not improve efficacy 3

When to Refer to a Specialist

• Failure to respond to first-line treatment measures 1, 2
• Diagnostic uncertainty 1, 2
• When second-line treatments (phototherapy, systemic immunosuppressants) are being considered 1, 2
• Maximum waiting time for specialist referral should be six weeks 3