What is the treatment for eczema on the lower legs?

Treatment of Eczema on the Lower Legs

Apply topical corticosteroids as first-line therapy using the least potent preparation that controls symptoms, no more than twice daily, combined with liberal emollient use. 1

Initial Treatment Approach

Topical Corticosteroid Selection

• Start with moderate-potency topical corticosteroids for moderate-to-severe eczema on the lower legs, as they achieve treatment success (cleared or marked improvement) in 52% of patients compared to 34% with mild-potency agents 2
• For severe presentations, potent topical corticosteroids result in 70% treatment success versus 39% with mild-potency preparations 2
• Apply once daily rather than twice daily—there is no additional benefit from more frequent application of potent topical corticosteroids 2, 3
• Use for short periods with "steroid holidays" when possible to minimize side effects 1

Essential Emollient Therapy

• Apply emollients liberally and regularly, even when eczema appears controlled—this is the cornerstone of maintenance therapy 1
• Apply emollients after bathing to provide a surface lipid film that retards water loss 1, 4
• Use soap-free cleansers and dispersible creams as soap substitutes, avoiding regular soaps and detergents that remove natural lipids 1, 4

Managing Secondary Complications

Bacterial Infection Recognition and Treatment

• Watch for increased crusting, weeping, or pustules indicating secondary bacterial infection 1
• Prescribe flucloxacillin as first-line oral antibiotic for Staphylococcus aureus, the most common pathogen 1, 4
• Use erythromycin for penicillin allergy or flucloxacillin resistance 4
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not delay or withhold steroids 1

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
• Initiate oral acyclovir early in the disease course 1, 4
• Administer acyclovir intravenously in ill, feverish patients 1

Adjunctive Symptom Management

Pruritus Control

• Prescribe sedating antihistamines for nighttime itching through their sedative properties, not anti-pruritic effects 1, 4
• Do not use non-sedating antihistamines—they have little to no value in atopic eczema 1, 3

Lichenified Eczema

• Consider ichthammol (1% in zinc ointment) or coal tar preparations for lichenified eczema on the lower legs 4, 5
• These preparations do not cause systemic side effects unless used extravagantly 5

Refractory Disease Options

Topical Calcineurin Inhibitors

• Consider tacrolimus 0.1% ointment once daily for areas where prolonged steroid use is concerning, providing a steroid-sparing effect 4
• Do not use pimecrolimus (ELIDEL) on children under 2 years old 6
• Use only for short periods with breaks in between, not continuously long-term 6
• Stop when signs and symptoms resolve 6

Phototherapy

• Narrow band ultraviolet B (312 nm) is an option for refractory cases 1
• Oral PUVA therapy shows 81-86% significant improvement or clearance in hand and foot eczema 4
• Be aware of long-term concerns including premature skin aging and cutaneous malignancies, particularly with PUVA 1

Systemic Corticosteroids

• Reserve oral steroids only for acute severe flares requiring rapid control when topical therapy has failed 1
• Use only for short-term "tiding over" during crisis periods after exhausting all other options 1
• Do not use for maintenance treatment—risk of pituitary-adrenal suppression and corticosteroid-related mortality 1

Critical Pitfalls to Avoid

• Do not apply topical corticosteroids more than twice daily—once daily is equally effective for potent preparations 1, 2
• Avoid very potent corticosteroids in thin-skinned areas, though lower legs are generally safe for potent preparations 1
• Address steroid phobia directly—72.5% of patients worry about topical corticosteroids, leading to 24% non-compliance, yet skin thinning occurred in only 1% of trial participants 7, 2
• Do not use emollient bath additives—they have not been shown to benefit eczema patients 3

When to Refer or Escalate

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks 1
• Need for systemic therapy or phototherapy 1
• Suspected eczema herpeticum (medical emergency) 1
• Diagnostic uncertainty or extensive disease 5