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. 1, 2

First-Line Treatment Approach

Topical Corticosteroids

• Apply topical corticosteroids no more than twice daily (once daily is equally effective) to affected areas only. 1, 2, 3
• Use the least potent preparation required to maintain control, escalating potency only when lower-strength agents fail. 1, 2
• Very potent and potent corticosteroids should be used with caution for limited periods only, particularly avoiding use on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is highest. 1, 2
• Implement "steroid holidays" (short breaks) when possible to minimize side effects, particularly pituitary-adrenal suppression and growth interference in children. 1, 2
• Stop topical corticosteroids when signs and symptoms (itching, rash, redness) resolve, or as directed. 2

Critical pitfall: Patients' or parents' fears of steroids frequently lead to undertreatment—you must explain the different potencies and the benefits/risks clearly to ensure adherence. 1, 2

Essential Adjunctive Measures

• Liberal use of emollients is the cornerstone of maintenance therapy—apply regularly even when eczema appears controlled. 2
• Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss. 1, 2
• Use dispersible cream as a soap substitute to cleanse the skin; avoid soaps and detergents that remove natural lipid. 1
• Regular bathing for cleansing and hydrating is recommended, with patients selecting the most suitable bath oil and regimen. 1, 2
• Keep nails short to minimize excoriation. 1
• Avoid extremes of temperature and irritant clothing such as wool next to skin; cotton clothing is preferred. 1

Managing Pruritus

• Sedating antihistamines (not non-sedating) may help with nighttime itching through their sedative properties only—use as short-term adjuvant during severe pruritus relapses. 1, 2, 3
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used. 1, 2, 3
• Large doses may be required in children; daytime use should be avoided. 1
• Therapeutic value may progressively reduce due to tachyphylaxis. 1

Managing Secondary Infections

Bacterial Infections

• Watch for signs of secondary bacterial infection: increased crusting, weeping, pustules, or failure to respond to treatment. 1, 2
• Flucloxacillin is first-line 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 patients with penicillin allergy. 1
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not delay or withhold them. 2

Important caveat: Recent evidence suggests oral or topical antistaphylococcal treatments for infected eczema lack strong supporting evidence and should be reconsidered. 3

Viral Infections (Eczema Herpeticum)

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

Second-Line Treatments for Sensitive Areas

Topical Calcineurin Inhibitors

• Pimecrolimus (Elidel) is useful for sensitive sites and should be used only after other prescription medicines have not worked or if your doctor recommends that other treatments should not be used. 4, 3
• Use only on areas with eczema, not continuously for long periods. 4
• Apply twice daily as a thin layer to affected areas only. 4
• Do not use on children under 2 years of age. 4
• Stop when signs and symptoms resolve; call your doctor if symptoms do not improve after 6 weeks. 4
• Avoid sun lamps, tanning beds, or ultraviolet light therapy during treatment; limit sun exposure even when medicine is not on skin. 4
• Most common side effect is burning or warmth at application site, usually mild to moderate, occurring during first 5 days and clearing within a few days. 4

Systemic Therapy for Severe Disease

When to Consider Systemic Treatment

• Failure to respond to moderate potency topical corticosteroids after 4 weeks warrants referral or escalation. 2
• Systemic immunosuppressive agents are recommended when disease activity cannot be controlled adequately with topical treatments. 5

Systemic Treatment Options

For short-term control:

• Cyclosporin is recommended as first option for patients with atopic eczema refractory to conventional treatment, with eleven studies consistently showing effectiveness. 5, 6
• Evidence from randomized controlled trials also exists for interferon-γ and azathioprine. 5
• Mycophenolate mofetil showed effectiveness in two small uncontrolled studies. 5

For biological therapy:

• Dupilumab ranks first for effectiveness among biological treatments, more effective than placebo in achieving EASI75 (RR 3.04,95% CI 2.51-3.69) and improvement in POEM score (mean difference 7.30,95% CI 6.61-8.00) at short-term follow-up. 7
• Low-certainty evidence indicates tralokinumab may be more effective than placebo in achieving short-term EASI75 (RR 2.54,95% CI 1.21-5.34). 7
• Dupilumab is associated with specific adverse events including eye inflammation and eosinophilia. 7

Oral corticosteroids:

• Systemic corticosteroids have a limited but definite role only for "tiding over" occasional patients during acute severe flares after all other treatment avenues have been explored. 1, 2
• The decision should never be taken lightly; they should not be considered for maintenance treatment. 1, 2
• Pituitary-adrenal suppression is a significant risk, particularly with prolonged use. 2
• Use of systemic corticosteroids is not generally recommended for chronic eczematous dermatitis. 8

Phototherapy

• Narrow band ultraviolet B (312 nm) has been introduced as an option. 1, 6
• Some concern exists about long-term adverse effects such as premature skin aging and cutaneous malignancies, particularly with PUVA. 1

Treatments to Avoid

Insufficient or negative evidence exists for:

• Probiotics for treating eczema 3
• Silk clothing 3
• Ion-exchange water softeners 3
• Emollient bath additives 3
• Emollients from birth for prevention (may result in harms such as increased skin infections and food allergy) 3
• Intravenous immunoglobulins and infliximab 5
• Homeopathy 6
• House dust mite reduction 6
• Evening primrose oil 6

When to Refer

• Failure to respond to first-line treatment measures after reinforcing compliance 1, 2
• Need for systemic therapy or phototherapy 2
• Suspected eczema herpeticum (medical emergency) 2
• Maximum waiting time of six weeks for first specialist appointment is recommended 1
• Access to patch testing facilities, dietitian, phototherapy unit, and clinical psychologist should be available 1