What is the typical treatment for eczema?

Treatment of Eczema (Atopic Dermatitis)

Start with topical corticosteroids as first-line therapy, using the least potent preparation that controls symptoms, applied once daily to affected areas, combined with liberal emollient use. 1, 2, 3

First-Line Treatment Algorithm

Topical Corticosteroids: The Cornerstone

• Apply topical corticosteroids once daily (not twice daily) to affected areas—once daily application is equally effective as more frequent use for potent corticosteroids 4, 5
• Select potency based on severity and location:
  • Mild eczema: Start with mild-potency topical corticosteroids 3
  • Moderate to severe eczema: Use moderate or potent topical corticosteroids, which are significantly more effective than mild preparations (70% vs 39% treatment success for potent vs mild) 6, 4
  • Very potent corticosteroids: Reserve for limited periods only, with short "steroid holidays" when possible 2
• Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is higher 2
• Continue topical corticosteroids even when bacterial infection is present, as long as appropriate systemic antibiotics are given concurrently 2

The evidence strongly supports this approach: potent and moderate topical corticosteroids are probably more effective than mild preparations (moderate-certainty evidence), with potent corticosteroids showing a large increase in treatment success (OR 3.71) 6, 4. Importantly, once-daily application is as effective as twice-daily use, reducing unnecessary exposure 4, 5.

Essential Emollient Therapy

• Apply emollients liberally and regularly, even when eczema appears controlled—this is the cornerstone of maintenance therapy 2, 3
• Apply emollients after bathing to provide a surface lipid film that retards water loss 1, 3
• Use soap-free cleansers and avoid alcohol-containing products, as soaps and detergents remove natural skin lipids 1, 2, 3

Managing Pruritus (Itching)

• Use sedating antihistamines exclusively at nighttime during severe pruritus episodes to help patients sleep through itching 1, 2, 3
• Large doses may be required in children to achieve adequate symptom control 1
• Avoid daytime use to prevent sedation 1
• Do not use non-sedating antihistamines—they have little to no value in atopic eczema and should not be used routinely 1, 2, 3, 5

This recommendation is critical: sedating antihistamines work through their sedative properties, not through histamine blockade, and are only useful for short-term adjuvant therapy during relapses 1. Non-sedating antihistamines lack evidence of benefit and should be dropped from practice 5.

Managing Secondary Bacterial Infection

Watch for these specific signs of bacterial superinfection: increased crusting, weeping, pustules, or failure to respond to topical treatment 1, 2

• First-line antibiotic: Flucloxacillin for Staphylococcus aureus, the most common pathogen 1, 2, 3
• Alternative: Erythromycin for penicillin allergy or flucloxacillin resistance 1
• Use phenoxymethylpenicillin if beta-hemolytic streptococci are isolated 1
• Do not delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given 2

Eczema Herpeticum: A Medical Emergency

Suspect eczema herpeticum if you observe: grouped vesicles, punched-out erosions, or sudden deterioration with fever 1, 2

• Initiate oral acyclovir immediately early in the disease course 1, 2
• Use intravenous acyclovir in ill, feverish patients 7, 2

Proactive (Weekend) Therapy to Prevent Flares

• Apply topical corticosteroids twice weekly (weekend therapy) to previously affected areas after initial control is achieved 4
• This approach probably results in a large decrease in likelihood of relapse from 58% to 25% (RR 0.43, moderate-certainty evidence) 4

When to Escalate to Systemic Therapy

Systemic corticosteroids have a limited but definite role only for occasional patients with severe atopic eczema who have failed all other treatments. 7, 1, 2, 3

Critical Restrictions on Oral Steroids

• Never use for maintenance treatment until all other avenues have been explored 7, 1, 2, 3
• Try to avoid during acute crises—they should only "tide over" occasional patients 7, 2
• Significant risks include: pituitary-adrenal suppression and possible interference with growth in children 1, 2

Other Second-Line Options

• Narrow band ultraviolet B (312 nm) phototherapy for moderate-to-severe disease 7, 2
• Newer agents (azathioprine, cyclosporin) remain experimental 7

Common Pitfalls to Avoid

• Steroid phobia leads to undertreatment—explain different potencies and benefits/risks clearly to patients and parents 2
• Do not apply topical corticosteroids more frequently than recommended—this doesn't improve efficacy but increases side effect risk 3
• Tachyphylaxis develops with prolonged antihistamine use, progressively reducing effectiveness 1
• Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when possible 2

Safety Profile of Topical Corticosteroids

Short-term use (median 3 weeks) of topical corticosteroids does not increase skin thinning risk, even with very potent preparations (low-certainty evidence) 6, 4. Only 26 cases of abnormal skin thinning were identified from 2266 participants across 22 trials (1%), with most cases from higher-potency preparations 4. However, longer-term use (6-60 months) showed increased skin thinning with mild to potent topical corticosteroids versus topical calcineurin inhibitors 6.

When to Refer to a Specialist

• 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
• Failure to respond to first-line management 7

Adjunctive Measures

• Keep nails short to minimize scratching damage 1, 3
• Avoid irritant clothing (wool)—wear cotton next to skin 1
• Avoid temperature extremes 1
• Consider dietary trial only when patient history strongly suggests specific food allergy or when widespread active eczema fails first-line treatment 7, 1

Treatments to Avoid

• Evening primrose oil: No conclusions can be drawn from available data, with two large trials showing no benefit 7
• Chinese herbal medicines: Hepatotoxicity has been reported; if patients wish to try, advise regular liver function tests 7
• House dust mite eradication: Evidence for benefits is not strong, and no effective measures for complete eradication currently exist 7

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