What is the treatment for papulopruritic eczema?

Treatment for Papulopruritic Eczema

First-Line Treatment: Topical Corticosteroids

Topical corticosteroids are the mainstay of treatment for papulopruritic eczema and should be initiated as first-line therapy. 1, 2

Selecting Corticosteroid Potency

• Use the least potent preparation that adequately controls the eczema. 1, 2
• For moderate to severe eczema, potent topical corticosteroids are significantly more effective than mild-potency preparations (70% vs 39% treatment success rate). 3
• Moderate-potency corticosteroids also demonstrate superior efficacy compared to mild preparations (52% vs 34% treatment success). 3
• Very potent corticosteroids should be reserved for severe, refractory cases and used with extreme caution for limited periods only. 1

Application Frequency and Duration

• Apply topical corticosteroids twice daily to affected areas only. 1, 4
• Evidence shows once-daily application of potent corticosteroids is equally effective as twice-daily application for treating flare-ups. 3
• Implement "steroid holidays" (short breaks) when possible to minimize the risk of pituitary-adrenal suppression and skin atrophy. 1, 2
• Stop topical corticosteroids when signs and symptoms (itching, rash, redness) resolve, or continue as directed by severity. 5

Essential Adjunctive Therapy: Emollients

• Apply emollients liberally and regularly, even when eczema appears controlled. 1, 2
• Emollients are most effective when applied immediately after bathing to provide a surface lipid film that prevents water loss. 1
• Use alcohol-free moisturizers, preferably containing 5-10% urea. 1
• If using both emollients and topical corticosteroids, apply the corticosteroid first, then the emollient. 5

Skin Care and Avoidance Measures

• Use soap-free cleansers (dispersible creams) as soap substitutes since soaps and detergents strip natural skin lipids. 1, 2
• Avoid frequent washing with hot water (hand washing, showers, baths). 1
• Avoid skin irritants including over-the-counter anti-acne medications, solvents, and disinfectants. 1
• Keep nails short to minimize excoriation. 1
• Avoid irritant clothing such as wool; cotton clothing worn next to the skin is preferred. 1
• Limit sun exposure and use SPF 15 sunscreen on exposed areas, reapplying every 2 hours when outdoors. 1

Managing Pruritus

• Sedating antihistamines (e.g., hydroxyzine, diphenhydramine) are useful short-term adjuncts during severe pruritus, primarily through their sedative properties rather than direct anti-pruritic effects. 1, 2
• Use sedating antihistamines at bedtime only; avoid daytime use. 1
• Large doses may be required in children. 1
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used. 1, 2
• Be aware that tachyphylaxis may progressively reduce antihistamine effectiveness. 1

Managing Secondary Bacterial Infection

Do not delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given concurrently. 2

Recognizing Infection

• Watch for increased crusting, weeping, pustules, or yellow discharge. 1, 2
• Painful skin lesions, pustules on arms/legs/trunk suggest bacterial superinfection. 1

Antibiotic Selection

• Flucloxacillin is first-line for Staphylococcus aureus, the most common pathogen. 1, 2
• Phenoxymethylpenicillin should be given if β-hemolytic streptococci are isolated. 1
• Erythromycin may be used for flucloxacillin resistance or penicillin allergy. 1
• Obtain bacterial cultures if infection is suspected and administer antibiotics for at least 14 days based on sensitivities. 1

Managing Eczema Herpeticum (Medical Emergency)

• Suspect eczema herpeticum if you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever. 1, 2
• Initiate oral acyclovir early in the disease course. 1, 2
• In ill, feverish patients, administer acyclovir intravenously. 1, 2

Proactive (Weekend) Therapy to Prevent Relapses

• For patients with frequent flare-ups, apply topical corticosteroids twice weekly (e.g., weekends) to previously affected areas to prevent relapse. 3
• This proactive approach reduces relapse likelihood from 58% to 25% compared to reactive use only. 3
• Continue emollients daily between corticosteroid applications. 2

Additional Treatment Options for Lichenified Eczema

• Ichthammol (1% in zinc ointment) or coal tar preparations can be particularly useful for healing lichenified (thickened) eczema. 1
• Coal tar solution (1% in hydrocortisone ointment) is generally preferred to crude coal tar. 1
• Paste bandages containing ichthammol may be applied for lichenified areas. 1

Second-Line Topical Therapy

• Pimecrolimus cream 1% (Elidel) is indicated for short-term treatment in patients age 2 years and older when other prescription medicines have not worked or are not recommended. 5
• Apply a thin layer twice daily only to affected areas. 5
• Stop when symptoms resolve (itching, rash, redness). 5
• Do not use continuously for long periods due to uncertain long-term safety regarding potential cancer risk. 5
• Avoid sun exposure, tanning beds, and UV light therapy during treatment with pimecrolimus. 5

Systemic Therapy for Severe, Refractory Cases

Phototherapy

• Narrow-band UVB (312 nm) phototherapy is an option for moderate to severe eczema. 1
• PUVA may be effective for papular dermatitis, with the best response rates among phototherapy options. 6
• Be aware of long-term concerns including premature skin aging and cutaneous malignancies, particularly with PUVA. 1
• Maintenance treatments may be necessary for long-term control due to frequent relapse. 6

Systemic Corticosteroids

• Systemic corticosteroids have a limited but definite role for severe atopic eczema to "tide over" occasional patients during acute crises. 1, 2
• This decision should never be taken lightly and only after exhausting all other options. 1, 2
• Do not use systemic steroids for maintenance treatment. 1, 2
• The main risk is pituitary-adrenal suppression with possible growth interference in children. 1

Other Systemic Agents for Refractory Papular Dermatitis

• Low-dose weekly methotrexate (2.5-10 mg) provides disease control in the majority of refractory cases. 7
• Azathioprine and mycophenolate mofetil are effective alternatives, though gastrointestinal side effects may limit azathioprine use long-term. 7
• These agents should be considered for patients refractory to topical therapy and phototherapy. 7

Critical Pitfalls to Avoid

• Do not withhold topical corticosteroids due to fear of side effects—undertreatment is common due to patients' or parents' steroid fears. 1, 2
• Do not use topical corticosteroids continuously without breaks—implement steroid holidays. 1, 2
• Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is higher. 2
• Do not use pimecrolimus in children under 2 years of age. 5
• Do not cover treated skin with bandages, dressings, or wraps unless specifically using wet-wrap therapy under supervision. 5

When to Refer or Escalate Care

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks. 2
• Symptoms do not improve after 6 weeks of treatment. 5
• Need for systemic therapy or phototherapy. 2
• Suspected eczema herpeticum (medical emergency). 2
• Symptoms worsen or skin infection develops during treatment. 5