What is the recommended treatment for eczema lesions?

Treatment for Eczema Lesions

Topical corticosteroids are the mainstay of treatment for eczema and should be applied using the least potent preparation that effectively controls symptoms, combined with regular emollient use and soap avoidance. 1, 2, 3

First-Line Treatment Strategy

Topical Corticosteroids

• Apply topical corticosteroids no more than twice daily to affected areas, using the least potent preparation that controls the eczema. 1, 2, 3
• Potent and moderate-potency topical corticosteroids are significantly more effective than mild-potency preparations for moderate to severe eczema, with potent corticosteroids achieving treatment success in 70% versus 39% with mild preparations. 4, 5
• Once-daily application of potent topical corticosteroids is equally effective as twice-daily application, so once-daily dosing is sufficient. 2, 5
• Very potent and potent corticosteroids should be used with caution for limited periods only, with short "steroid holidays" when possible to minimize side effects. 1, 3
• Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where risk of atrophy is higher; use mild to moderate potency corticosteroids on facial eczema instead. 2, 3

Essential Emollient Therapy

• Liberal use of emollients is the cornerstone of maintenance therapy and must be applied regularly, even when eczema appears controlled. 3
• Apply emollients immediately after bathing to provide a surface lipid film that retards evaporative water loss from the epidermis. 1, 2, 3
• Use a dispersible cream as a soap substitute instead of regular soaps and detergents that remove natural skin lipids. 1, 2
• Regular bathing is beneficial for cleansing and hydrating the skin. 1, 2

Avoidance Measures

• Avoid extremes of temperature and irritant clothing such as wool; cotton clothing is preferred. 1, 2
• Keep nails short to minimize damage from scratching and reduce risk of secondary infection. 1, 2

Managing Secondary Infections

Bacterial Infections

• Watch for signs of secondary bacterial infection: crusting, weeping, or pustules. 1, 3
• Flucloxacillin is the first-line oral antibiotic for Staphylococcus aureus, the most common pathogen. 1, 2, 3
• Phenoxymethylpenicillin should be given if β-hemolytic streptococci are isolated. 1
• Erythromycin may be used when there is resistance to flucloxacillin or in patients with penicillin allergy. 1
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently. 3

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, 3
• Initiate oral acyclovir early in the disease course. 1, 2, 3
• In ill, feverish patients, administer acyclovir intravenously. 1, 3

Second-Line Treatment Options

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% is among the most effective treatments, ranked similarly to potent topical corticosteroids for improving patient symptoms and clinician signs. 4, 6
• Tacrolimus 0.1% and pimecrolimus 1% are most likely to cause local application-site reactions (burning, stinging, pruritus), particularly during the first few days of application. 7, 4
• Pimecrolimus should not be used on malignant or pre-malignant skin conditions, in patients with Netherton's Syndrome, or in immunocompromised patients. 7
• Patients using topical calcineurin inhibitors should minimize or avoid natural or artificial sunlight exposure. 7

JAK Inhibitors

• Ruxolitinib 1.5% and delgocitinib 0.5% or 0.25% are ranked among the most effective treatments, with effectiveness similar to potent topical corticosteroids. 4, 6

Tar Preparations

• Ichthammol (1% in zinc ointment) is less irritant than coal tars and particularly useful for lichenified eczema. 1
• Coal tar solution (1% in hydrocortisone ointment) is generally preferred to crude coal tar and does not cause systemic side effects unless used extravagantly. 1

Antihistamines

• Sedating antihistamines are useful as short-term adjuvants during relapses with severe pruritus, primarily for their sedative properties to help with nighttime itching. 1, 3
• Use antihistamines primarily at night while asleep; avoid daytime use. 1
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used. 1, 3

Proactive (Weekend) Therapy for Relapse Prevention

• Weekend (proactive) therapy with topical corticosteroids applied twice weekly to commonly affected areas probably results in a large decrease in likelihood of relapse from 58% to 25%. 5
• This approach is an important therapeutic option for long-term maintenance treatment of moderate to severe disease. 8

Third-Line Treatment Options

Phototherapy

• Narrow band ultraviolet B (312 nm) phototherapy is an option for moderate to severe eczema not responding to first-line treatments. 1, 3
• Some concern exists about long-term adverse effects such as premature skin aging and cutaneous malignancies, particularly with PUVA. 1, 3

Systemic Corticosteroids

• Systemic corticosteroids have a limited but definite role only for tiding occasional patients with severe atopic eczema through acute crises after all other treatment avenues have been explored. 1, 3
• They should not be considered for maintenance treatment. 1, 3
• Pituitary-adrenal suppression is a significant risk, particularly with prolonged use. 3

Safety Considerations for Topical Corticosteroids

Short-Term Use

• Abnormal skin thinning occurred in only 1% of participants across 22 short-term trials (median 3 weeks), with most cases from higher-potency preparations. 5
• Short-term use of any topical corticosteroid potency (1-16 weeks) did not show evidence for increased skin thinning. 4, 5

Long-Term Use

• Skin thinning was reported in 6/2044 (0.3%) participants treated with longer-term (6-60 months) mild to potent topical corticosteroids. 4
• The main risk with prolonged use is suppression of the pituitary-adrenal axis with possible interference of growth in children. 1

When to Refer to a Specialist

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks. 3
• Need for systemic therapy or phototherapy. 3
• Suspected eczema herpeticum (medical emergency). 3
• Extensive disease or diagnostic uncertainty. 2

Common Pitfalls to Avoid

• Do not delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given concurrently. 3
• Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when possible. 3
• Patients' or parents' fears of steroids often lead to undertreatment—explain the different potencies and the benefits/risks clearly. 1, 3
• Do not use non-sedating antihistamines, as they have no value in atopic eczema. 1, 3