What is the first-line treatment for eczema?

First-Line Treatment for Eczema

The first-line treatment for eczema consists of liberal emollient use combined with topical corticosteroids applied to active lesions, using the least potent preparation that effectively controls the disease. 1, 2

Core Treatment Strategy

Emollient Therapy (Foundation of All Treatment)

• Apply emollients liberally and frequently to maintain skin hydration and restore the impaired epidermal barrier that characterizes eczema 3, 4
• Emollients are most effective when applied immediately after bathing to trap moisture and prevent evaporative water loss 2
• Replace regular soaps with soap substitutes (dispersible creams) to avoid stripping natural skin lipids that worsen barrier dysfunction 2, 3
• Regular bathing is beneficial for cleansing and hydrating the skin, contrary to older beliefs about avoiding water exposure 2

Topical Corticosteroid Therapy (Primary Anti-Inflammatory Treatment)

• Use the least potent topical corticosteroid that controls the eczema, following a step-up approach based on severity and location 1, 2
• Apply once daily rather than twice daily - potent topical corticosteroids applied once daily are equally effective as twice-daily application, reducing unnecessary exposure 2, 5
• Treatment should not be applied more than twice daily even for severe disease 1

Potency Selection by Severity and Location:

• Mild eczema or facial/intertriginous areas: Start with mild-potency corticosteroids (1% hydrocortisone) due to thinner skin and increased absorption risk 2, 3
• Moderate eczema: Use moderate-potency topical corticosteroids, which achieve treatment success in 52% versus 34% with mild potency 5, 6
• Severe eczema or lichenified areas: Use potent topical corticosteroids, which achieve treatment success in 70% versus 39% with mild potency 5, 6
• Very potent topical corticosteroids should be reserved for very severe disease and used with caution for limited periods only 1

The evidence strongly supports that potent topical corticosteroids, along with tacrolimus 0.1% and JAK inhibitors, are consistently ranked among the most effective treatments in network meta-analyses, while mild topical corticosteroids and PDE-4 inhibitors rank among the least effective 6, 7

Adjunctive Measures

• Keep nails short to minimize skin damage from scratching and reduce secondary infection risk 2
• Avoid extreme temperatures and irritant clothing such as wool; cotton clothing is preferred 2

Maintenance and Flare Prevention

Proactive (Weekend) Therapy

• After achieving control of active eczema, apply topical corticosteroids twice weekly (weekend therapy) to previously affected areas to prevent relapse 5
• This proactive approach reduces relapse rates from 58% to 25% compared to reactive treatment only (treating flares as they occur) 5
• Continue daily emollient use between topical corticosteroid applications 5

Managing Secondary Complications

Bacterial Infections

• Flucloxacillin is the first-line antibiotic for treating overt secondary bacterial infection with Staphylococcus aureus, the most common pathogen 1, 2, 3
• Use phenoxymethylpenicillin if β-hemolytic streptococci are isolated 1, 2
• Erythromycin is appropriate for penicillin-allergic patients 1, 2

Viral Infections

• Eczema herpeticum requires prompt oral acyclovir started early in the disease course 1, 2
• In ill, febrile patients, administer acyclovir intravenously 1, 2

Role of Antihistamines

Sedating antihistamines may be used as short-term adjuvants during severe flares with significant pruritus, primarily for their sedative properties to reduce nighttime scratching 1, 2, 3

Non-sedating antihistamines have little to no value in treating eczema and should not be routinely used 1, 2, 3, 8

Safety Considerations

Topical Corticosteroid Safety

• Short-term use (median 3 weeks) of topical corticosteroids does not increase skin thinning risk, even with potent or very potent preparations 6
• The risk of skin thinning increases with longer-term use (6-60 months), occurring in approximately 0.3% of patients 6, 7
• Infants are particularly susceptible to systemic absorption due to high body surface area to volume ratio, requiring careful monitoring 3
• The main risk with prolonged use is pituitary-adrenal axis suppression, particularly in children 1
• Application-site reactions are least common with topical corticosteroids compared to other anti-inflammatory agents 6, 7

Topical Calcineurin Inhibitor Considerations

• While tacrolimus 0.1% ranks among the most effective treatments, it has the highest rate of application-site reactions (burning, stinging) 6, 7
• Tacrolimus and pimecrolimus can be used as steroid-sparing agents for sensitive areas like the face 4

When to Refer to a Specialist

Refer to dermatology when:

• Failure to respond to first-line treatment 1, 2, 3
• Diagnostic uncertainty 3
• Extensive disease requiring second-line treatments 3
• Need for systemic therapy consideration 1

Common Pitfalls to Avoid

• Do not use topical or oral antistaphylococcal antibiotics routinely for non-infected eczema - there is insufficient evidence to support this practice 8
• Avoid systemic corticosteroids for maintenance therapy - they should only be used to tide over occasional severe flares after all other options are exhausted 1
• Do not continue ineffective treatments - if no response occurs after a reasonable trial period, escalate therapy or refer 1
• Emollients from birth do not prevent eczema and may increase risks of skin infections and food allergy, contrary to previous recommendations 8