Treatment of Eczema (Atopic Dermatitis)
First-Line Treatment: Topical Corticosteroids
Topical corticosteroids are the mainstay of eczema treatment and should be initiated as first-line therapy, using the least potent preparation that adequately controls symptoms. 1
Potency Selection and Application
Start with moderate-potency topical corticosteroids for most cases of eczema, as they achieve treatment success in 52% of patients compared to 34% with mild-potency agents (OR 2.07) 1, 2
Potent topical corticosteroids are highly effective for moderate-to-severe eczema, achieving 70% treatment success versus 39% with mild-potency agents (OR 3.71), and rank among the most effective treatments alongside tacrolimus 0.1% and JAK inhibitors 2, 3
Apply topical corticosteroids no more than twice daily to affected areas 1, 4
Once-daily application of potent topical corticosteroids is as effective as twice-daily application (OR 0.97), allowing for simplified regimens without loss of efficacy 2
Avoid very potent and potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is higher; use mild-to-moderate potency agents (hydrocortisone 1-2.5% or prednicarbate 0.02%) in these locations 1, 5
Implement short "steroid holidays" when possible to minimize side effects, discontinuing for brief periods when control is achieved 1
Safety Profile of Topical Corticosteroids
Short-term use (median 3 weeks, range 1-16 weeks) of topical corticosteroids does not increase risk of skin thinning, with only 36 events reported across 3,691 participants in 25 trials 3, 6
Longer-term intermittent use (up to 5 years) for flare management probably results in little to no difference in growth abnormalities, infections, or malignancies in children, based on two RCTs with 2,570 participants 6
Topical corticosteroids are least likely to cause application-site reactions compared to other anti-inflammatory agents 3
Watch for systemic absorption risks with prolonged use over large surface areas or under occlusive dressings, particularly in children who have larger skin surface area to body weight ratios and are more susceptible to HPA axis suppression 4
Essential Adjunctive Therapy: Emollients
Liberal use of emollients is the cornerstone of maintenance therapy and must be applied regularly, even when eczema appears controlled. 1, 7
Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss 1, 7
Use soap-free cleansers and avoid alcohol-containing products on all affected areas 1, 5
Regular bathing for cleansing and hydrating the skin is recommended, with patients determining their most suitable bath oil and bathing regimen 7
Managing Pruritus (Itching)
Sedating antihistamines (diphenhydramine, clemastine) may help with nighttime itching through their sedative properties, not through direct anti-pruritic effects 1, 5
Non-sedating antihistamines have little to no value in atopic eczema and should not be used 1, 7
Use antihistamines primarily at night while asleep; avoid daytime use 7
Managing Secondary Infections
Bacterial Infections
Watch for signs of secondary bacterial infection: increased crusting, weeping, or pustules 1, 5
Flucloxacillin is the first-line oral antibiotic for Staphylococcus aureus, the most common pathogen in infected eczema 1, 7
Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not delay or withhold topical corticosteroids when infection is present 1
Eczema Herpeticum (Medical Emergency)
If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum and initiate treatment immediately 1, 5
Initiate oral acyclovir early in the disease course for stable patients 1, 7
Administer acyclovir intravenously in ill, feverish patients—this is a medical emergency requiring urgent treatment 1, 5
Second-Line Topical Treatments
Topical Calcineurin Inhibitors
Topical calcineurin inhibitors (tacrolimus ointment, pimecrolimus cream) are considered second-line therapy when topical corticosteroids are insufficient or inappropriate 8, 9
Tacrolimus 0.1% ranks among the most effective treatments (OR 5.06 for treatment success), with effectiveness similar to potent topical corticosteroids 3
Tacrolimus 0.1% and pimecrolimus 1% are most likely to cause local application-site reactions (OR 2.2 and 1.44 respectively), which is their primary limitation 3
Phosphodiesterase-4 (PDE-4) Inhibitors
PDE-4 inhibitors (crisaborole 2%, roflumilast 0.15%) rank among the least effective topical anti-inflammatory treatments and should be reserved for cases where other options are contraindicated 3
Crisaborole 2% causes application-site reactions (OR 2.12) at rates similar to tacrolimus 3
JAK Inhibitors
Ruxolitinib 1.5% ranks among the most effective treatments (OR 9.34 for treatment success), with effectiveness similar to very potent topical corticosteroids 3
Delgocitinib 0.5% and 0.25% are highly effective (OR 10.08 and 6.87 respectively), ranking alongside very potent topical corticosteroids 3
Proactive (Weekend) Therapy to Prevent Flares
Weekend (proactive) therapy with topical corticosteroids applied twice weekly to previously affected areas probably results in a large decrease in likelihood of relapse from 58% to 25% (RR 0.43). 2
Apply topical corticosteroids twice weekly (e.g., weekends) to areas prone to flares after initial control is achieved, continuing for 16-20 weeks 2
No cases of abnormal skin thinning were identified in seven trials (1,050 participants) assessing proactive therapy, providing reassurance about this strategy 2
Systemic Therapy for Severe Disease
Phototherapy
Narrow-band UVB (312 nm) is an option for moderate-to-severe eczema inadequately controlled with topical therapy 1, 8
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 through acute crises 1
Use oral steroids only for short-term "tiding over" during crisis periods after exhausting all other options, including optimized topical corticosteroids, emollients, infection management, and consideration of second-line treatments 1
Do not use oral steroids for maintenance treatment or to induce stable remission 1
Pituitary-adrenal suppression is a significant risk with prolonged use, with corticosteroid-related mortality documented in other inflammatory conditions (up to 77% of deaths in pemphigus vulgaris being steroid-related) 1
Other Systemic Options
Cyclosporine is considered the gold standard systemic therapy for severe eczema inadequately controlled with topical treatments 8
Other traditional systemic therapies include methotrexate, azathioprine, and mycophenolate mofetil for severe cases 8
When to Refer or Escalate
Refer if there is failure to respond to moderate-potency topical corticosteroids after 4 weeks 1, 5
Refer immediately if eczema herpeticum is suspected—this is a medical emergency 1, 5
Common Pitfalls to Avoid
Patients' or parents' fears of steroids often lead to undertreatment—explain the different potencies and the benefits/risks clearly to ensure adequate treatment 1
Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when control is achieved 1
Avoid very potent corticosteroids in thin-skinned areas where risk of atrophy is higher 1