What topical treatments are available for eczema?

Topical Treatments for Eczema

For eczema, start with topical corticosteroids as first-line therapy, selecting the least potent preparation that controls symptoms—typically moderate-potency (mometasone furoate 0.1%) for body/extremities and low-potency (hydrocortisone 1%) for face/neck/genitals—applied twice daily until lesions clear, then transition to twice-weekly maintenance to prevent flares. 1, 2, 3

First-Line Treatment: Topical Corticosteroids

Initial Management by Body Site

• For trunk and extremities: Begin with moderate-potency topical corticosteroids (mometasone furoate 0.1% ointment) applied twice daily to affected areas 3
• For face, neck, genitals, and body folds: Use only low-potency agents (hydrocortisone 1%) to minimize risk of skin atrophy and systemic absorption 2
• Duration: Apply twice daily for 2-4 weeks maximum at full strength for moderate-potency steroids; up to 12 weeks for lower potencies 4

The American Academy of Dermatology strongly recommends topical corticosteroids as first-line treatment, with selection based on a 7-class potency system (Class I being very high potency like clobetasol 0.05%, Class VII being low potency like hydrocortisone 1%) 2. Once daily application may be sufficient for potent topical corticosteroids, as moderate-certainty evidence shows no difference in effectiveness between once versus twice daily application 5.

Stepping Down Therapy

• If significant improvement occurs within 2 weeks: Step down to lower potency corticosteroid while continuing twice-daily application 3
• If minimal or no improvement after 2 weeks: Consider secondary bacterial infection (particularly Staphylococcus aureus) and add oral flucloxacillin or erythromycin if penicillin-allergic 1, 3

Maintenance Therapy to Prevent Flares

After initial clearance, transition to twice-weekly application of medium-potency topical corticosteroids (e.g., fluticasone propionate 0.05% cream) to previously affected areas. 2, 3 This proactive "weekend therapy" approach reduces flare risk dramatically—patients are 7.0 times less likely to relapse compared to no maintenance treatment (95% CI: 3.0-16.7; P < .001) 2. Moderate-certainty evidence shows this reduces relapse likelihood from 58% to 25% (RR 0.43,95% CI 0.32 to 0.57) 5.

Essential Adjunctive Measures

Emollients and Skin Care

• Apply liberal amounts of emollients throughout the day, especially immediately after bathing while skin is still damp 1, 3
• Use emollients after topical corticosteroids, not before 1
• Replace soaps with dispersible cream as soap substitute to avoid stripping natural skin lipids 1, 3
• Avoid wool clothing and extreme temperatures; prefer cotton 1, 3

Regular bathing is beneficial for cleansing and hydrating, and emollients applied afterward provide a surface lipid film that retards evaporative water loss 1.

Second-Line Options: Topical Calcineurin Inhibitors

For patients concerned about corticosteroid side effects or requiring treatment of sensitive areas (face, eyelids), consider tacrolimus 0.03% or 0.1% ointment or pimecrolimus 1% cream. 2

Important Limitations and Warnings

• Do NOT use in children under 2 years old 6
• Avoid continuous long-term use—apply only to areas with active eczema for short periods with breaks between treatments 6
• Black box warning: Rare cases of malignancy (skin cancer, lymphoma) reported, though causal relationship not established 6
• Less effective than moderate/potent corticosteroids: Pimecrolimus is significantly less effective than 0.1% triamcinolone (RR 0.75,95% CI 0.67 to 0.83) and 0.1% betamethasone valerate (RR 0.61,95% CI 0.45 to 0.81) 7
• Common side effect: Skin burning/warmth sensation, typically mild-moderate and resolving within first 5 days 6

Tacrolimus 0.1% is more effective than pimecrolimus (RR 0.58,95% CI 0.46 to 0.74 for investigator global assessment) 7.

Potency Selection Algorithm

For Nummular Eczema (Coin-Shaped Plaques)

1. Start with high-potency topical corticosteroid (mometasone furoate 0.1% ointment) twice daily 3
2. Do NOT use very potent corticosteroids (clobetasol) as first-line—reserve for severe, refractory cases 3
3. Reassess after 2 weeks: If weeping, crusted, or non-responsive, add antibiotics for secondary infection 3

For Atopic Dermatitis by Severity

• Mild: Low-potency (hydrocortisone 1%) or moderate-potency for body 2
• Moderate: Moderate-potency (mometasone, triamcinolone 0.1%) 2
• Severe: Potent corticosteroids (betamethasone valerate 0.1%) for trunk/extremities only 2

Moderate-certainty evidence shows potent topical corticosteroids result in large increases in treatment success compared to mild-potency (70% versus 39%; OR 3.71,95% CI 2.04 to 6.72), but uncertain evidence exists for benefit of very potent over potent preparations 5.

Critical Pitfalls to Avoid

Application Errors

• Do NOT apply more than twice daily—no additional benefit and increases side effect risk 1, 2
• Do NOT use potent steroids on face, neck, or genitals—high risk of skin atrophy and systemic absorption 2
• Do NOT cover treated areas with occlusive dressings unless specifically directed—increases systemic absorption 6
• Do NOT bathe/shower immediately after application—washes off medication 6

Medication Selection Errors

• Do NOT prescribe non-sedating antihistamines for eczema—they have little to no value; sedating antihistamines at night only during severe pruritic episodes 1, 3
• Do NOT use alcohol-containing lotions—prefer ointments or oil-in-water creams which are less irritating 3
• Do NOT overlook secondary infection—if lesions are weeping, crusted, or not responding within 2 weeks to appropriate topical steroids, add antibiotics 3

Safety Monitoring

• In children, use lower potencies and shorter durations due to risk of pituitary-adrenal axis suppression 1, 4
• Limit high-potency steroid use to 2-4 weeks maximum—risk of skin atrophy, telangiectasias, hypopigmentation 2, 3
• Abnormal skin thinning risk increases with potency: Low overall frequency (1% across trials) but 16 cases with very potent, 6 with potent, 2 with moderate, 2 with mild preparations 5

Sun Protection During Treatment

• Minimize sun exposure during treatment, even when medication not on skin 6
• Do NOT use sun lamps, tanning beds, or UV light therapy while using topical calcineurin inhibitors 6
• Wear loose-fitting protective clothing if outdoors after application 6

Special Considerations for Specific Formulations

Ointment vs. Cream

• Ointments are generally preferred for dry, lichenified eczema—better occlusion and hydration 3
• Creams may be preferred for weeping lesions or intertriginous areas 4

Adjunctive Treatments for Specific Scenarios

• For lichenified eczema: Consider ichthammol 1% in zinc ointment—less irritant than coal tars 1
• For fissures: Propylene glycol 50% in water for 30 minutes under plastic occlusion nightly, followed by hydrocolloid dressing 8
• For secondary infection: Flucloxacillin for Staphylococcus aureus, phenoxymethylpenicillin for β-hemolytic streptococci, erythromycin for penicillin allergy 1
• For eczema herpeticum: Oral acyclovir early in disease course 1