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, applied no more than twice daily using the least potent preparation that controls symptoms. 1, 2

Core Treatment Algorithm

Step 1: Establish Foundation with Emollients and Skin Care

• Apply emollients liberally and regularly as the cornerstone of maintenance therapy, even when eczema appears controlled 2
• Apply emollients immediately after bathing to provide a surface lipid film that retards evaporative water loss from the epidermis 1, 2
• Use dispersible cream as a soap substitute instead of regular soaps and detergents, which remove natural lipid from already-dry skin 1
• Avoid alcohol-containing products 2
• Keep nails short to minimize damage from scratching 1
• Recommend cotton clothing next to the skin and avoid irritant materials like wool 1

Step 2: Initiate Topical Corticosteroids

Apply the basic principle: use the least potent preparation required to keep eczema under control, with short "steroid holidays" when possible. 1, 2

• Apply topical corticosteroids once daily (not twice daily, as recent evidence shows once-daily application is equally effective) 3
• Use very potent and potent corticosteroids with caution for limited periods only 1, 2
• Stop topical corticosteroids when signs and symptoms (itching, rash, redness) resolve, or as directed 4
• Consider the "get control then keep control" regimen for more aggressive disease management 3

Common pitfall to avoid: Patients' or parents' fears of steroids often lead to undertreatment—explain the different potencies and the benefits/risks clearly to improve adherence 1, 2

Step 3: Consider Topical Calcineurin Inhibitors for Sensitive Sites

• Pimecrolimus (Elidel) is useful for sensitive sites where corticosteroid atrophy risk is higher (face, neck, flexures, genitals) 4, 3
• Use only in patients age 2 years and older who do not have a weakened immune system 4
• Apply a thin layer twice daily only to affected skin areas 4
• Use for short periods with breaks in between; stop when symptoms resolve 4
• Do not use continuously for long periods due to uncertain long-term safety profile 4
• Most common side effect is burning or warmth at application site, typically mild and resolving within the first week 4

Step 4: Manage Secondary Infections Aggressively

Watch for deterioration in previously stable eczema—this may indicate secondary bacterial or viral infection. 1

For Bacterial Infection:

• Look for increased crusting, weeping, or pustules 2
• Prescribe flucloxacillin as first-line oral antibiotic for Staphylococcus aureus, the most common pathogen 1, 2
• Use phenoxymethylpenicillin if β-hemolytic streptococci are isolated 1
• Use erythromycin for flucloxacillin resistance or penicillin allergy 1
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently 2

Critical pitfall to avoid: Do not delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given 2

For Eczema Herpeticum (Medical Emergency):

• Suspect if you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever 1, 2
• Initiate oral acyclovir early in the disease course 1, 2
• Administer acyclovir intravenously in ill, feverish patients 1, 2

Step 5: Address Pruritus Selectively

• Use sedating antihistamines only for short-term adjuvant therapy during severe pruritus relapses, primarily for their sedative properties to help with nighttime itching 1, 2, 3
• Recommend nighttime use only; avoid daytime use 1
• Large doses may be required in children 1
• Do not prescribe non-sedating antihistamines—they have little to no value in atopic eczema 1, 2, 3

Evidence note: Recent high-quality evidence indicates oral antihistamines should be demoted from routine use, as there is little evidence to support their continued use 3

Step 6: Consider Adjunctive Tar Preparations

• Ichthammol (1% in zinc ointment) is less irritant than coal tar and may be applied as ointment or paste bandages, particularly useful for healing lichenified eczema 1
• Coal tar solution 1% in hydrocortisone ointment is adequate and does not cause systemic side effects unless used extravagantly 1

When to Escalate to Second-Line Treatments

Refer to specialist or escalate therapy if:

• 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

Second-Line Options (Specialist-Initiated):

Phototherapy:

• Narrow band ultraviolet B (312 nm) is an option for phototherapy 1, 2
• Some concern exists about long-term adverse effects such as premature skin aging and cutaneous malignancies, particularly with PUVA 1, 2

Systemic Immunosuppressants:

• Dupilumab is the most effective biological treatment for moderate to severe eczema, more effective than placebo in achieving EASI75 (RR 3.04,95% CI 2.51-3.69) and improvement in POEM score at short-term follow-up 5
• Dupilumab is associated with specific adverse events including eye inflammation and eosinophilia 5
• Tralokinumab may be more effective than placebo in achieving short-term EASI75 (RR 2.54,95% CI 1.21-5.34), though evidence is of low certainty 5

Oral Corticosteroids (Use with Extreme Caution):

• 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
• Should never be used for maintenance treatment 1, 2, 6
• Significant risk of pituitary-adrenal suppression, particularly with prolonged use 2
• Corticosteroid-related mortality has been documented in other inflammatory conditions 2

Treatments to Avoid (Insufficient Evidence)

Do not routinely use the following, as recent evidence does not support their efficacy: 3

• Oral or topical antistaphylococcal treatments for infected eczema (use systemic antibiotics only for overt infection)
• Probiotics for treating eczema
• Silk clothing
• Ion-exchange water softeners
• Emollient bath additives
• Evening primrose oil 1

Avoid emollients from birth for prevention—large trials suggest they do not prevent eczema and may result in harms such as increased skin infections and food allergy 3

Monitoring and Follow-Up

• Call patients back if symptoms get worse, skin infection develops, or symptoms do not improve after 6 weeks of treatment 4
• Bacteriological swabs are not routinely indicated but may be necessary if patients do not respond to treatment 1
• Maximum waiting time of 6 weeks for first specialist appointment if referral needed 1