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, applied no more than twice daily. 1

Core Treatment Strategy

Topical Corticosteroids - Primary Treatment

• Use the least potent corticosteroid preparation required to achieve control, applying once daily rather than twice daily. 1, 2
• Very potent and potent corticosteroids should be reserved for limited periods only, with mandatory "steroid holidays" when control is achieved to minimize side effects including pituitary-adrenal suppression and growth interference in children. 3, 1
• Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is highest. 1
• A common pitfall is undertreatment due to patient or parent steroid fears—explain clearly that different potencies exist and that appropriate use is safe. 3, 1

Essential Maintenance Therapy

• Liberal emollient use is the cornerstone of maintenance therapy and must be applied regularly, even when eczema appears controlled. 1
• Apply emollients immediately after bathing to create a surface lipid film that prevents water loss from the epidermis. 3, 1
• Use dispersible cream as a soap substitute rather than traditional soaps and detergents, which strip natural lipids and worsen dry skin. 3
• Regular bathing for cleansing and hydrating is beneficial—allow patients to determine their preferred bathing regimen. 3, 1

Topical Calcineurin Inhibitors

• Pimecrolimus and tacrolimus are useful for sensitive sites and can be used in conjunction with topical corticosteroids as first-line treatment. 2, 4

Managing Pruritus

• Use sedating antihistamines only for short-term nighttime relief during severe flares—their benefit comes from sedation, not anti-pruritic effects. 3, 1
• Non-sedating antihistamines have no value in atopic eczema and should not be prescribed. 1, 2
• Large doses may be required in children, but avoid daytime use. 3
• Tachyphylaxis progressively reduces antihistamine effectiveness over time. 3

Managing Secondary Infections

Bacterial Infections

• Watch for increased crusting, weeping, pustules, or failure to respond to treatment—these indicate secondary bacterial infection. 3, 1
• Flucloxacillin is first-line for Staphylococcus aureus, the most common pathogen. 3, 1
• Use phenoxymethylpenicillin if β-hemolytic streptococci are isolated. 3
• Erythromycin is appropriate for flucloxacillin resistance or penicillin allergy. 3
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not withhold them. 1
• Topical or oral antistaphylococcal treatments for infected eczema lack supporting evidence and should be avoided. 2

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. 1
• Initiate oral acyclovir early in the disease course. 3, 1
• In ill, feverish patients, administer acyclovir intravenously. 3, 1

Systemic Therapy for Severe Disease

When to Consider Systemic Treatment

• Reserve for patients with disease activity that cannot be controlled adequately with optimized topical treatments. 5
• Failure to respond to moderate potency topical corticosteroids after 4 weeks warrants referral or escalation. 1

Systemic Immunosuppressive Agents

• Cyclosporine is recommended as the first-option systemic agent for eczema refractory to conventional treatment, with consistent evidence from 11 studies. 5
• Evidence from randomized controlled trials also supports interferon-γ and azathioprine. 5
• Mycophenolate mofetil showed effectiveness in small uncontrolled studies. 5
• Dupilumab is the most effective biological treatment, achieving EASI75 improvement (RR 3.04,95% CI 2.51-3.69) compared to placebo at short-term follow-up. 6
• Dupilumab is associated with specific adverse events including eye inflammation and eosinophilia. 6
• Intravenous immunoglobulins and infliximab are not recommended based on published data. 5

Oral Corticosteroids - Use With Extreme Caution

• Systemic corticosteroids should only be used for short-term "tiding over" during acute severe flares after exhausting all other options—never for maintenance treatment. 1
• Systemic corticosteroids are generally not recommended for chronic eczematous dermatitis. 7
• Significant risks include pituitary-adrenal suppression and corticosteroid-related mortality documented in other inflammatory conditions. 1

Phototherapy

• Narrow band ultraviolet B (312 nm) is a safe and effective option for moderate to severe disease when first-line treatments are inadequate. 3, 4
• Concern exists about long-term adverse effects including premature skin aging and cutaneous malignancies, particularly with PUVA. 3

Lifestyle Modifications

• Keep nails short to minimize damage from scratching. 3
• Avoid extremes of temperature. 3
• Wear cotton clothing next to skin rather than irritant materials like wool. 3

Treatments to Avoid

• Emollient bath additives have not been shown to benefit eczema patients. 2
• Silk clothing and ion-exchange water softeners lack evidence of benefit. 2
• Probiotics for treating eczema are not supported by evidence. 2
• Emollients from birth do not prevent eczema and may increase skin infections and food allergy. 2

When to Refer

• Failure to respond to moderate potency topical corticosteroids after 4 weeks. 1
• Need for systemic therapy or phototherapy. 1
• Suspected eczema herpeticum (medical emergency requiring immediate intervention). 1
• Maximum waiting time for first specialist appointment should be 6 weeks. 3