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 beta-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
• Dupilumab is the most effective biological treatment, more effective than placebo in achieving EASI75 (RR 3.04,95% CI 2.51-3.69) and POEM improvement (mean difference 7.30,95% CI 6.61-8.00) at short-term follow-up. 6
• Dupilumab has favorable short-term safety with lower SAEs compared to placebo, though it is associated with specific adverse events including eye inflammation and eosinophilia. 6
• Evidence also exists for interferon-γ and azathioprine from randomized controlled trials. 5
• Tralokinumab may be more effective than placebo (RR 2.54,95% CI 1.21-5.34), but evidence is of low certainty. 6

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
• Pituitary-adrenal suppression is a significant risk, particularly with prolonged use. 1
• Systemic corticosteroids are not generally recommended for chronic eczematous dermatitis. 7
• Although frequently used in clinical practice, they have not been adequately assessed in studies. 5

Phototherapy

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

Treatments to Avoid

• Do not use probiotics—there is little evidence supporting their use for treating eczema. 2
• Emollient bath additives have not been shown to benefit eczema patients. 2
• Silk clothing and ion-exchange water softeners lack evidence of benefit. 2
• Intravenous immunoglobulins and infliximab are not recommended based on published data. 5
• Emollients from birth do not prevent eczema and may result in harms such as increased skin infections and food allergy. 2

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