What is the initial management of eczema?

Initial Management of Eczema

Start with liberal emollient use combined with the least potent topical corticosteroid that controls symptoms, applied once daily to affected areas only. 1, 2

First-Line Treatment Foundation

Emollients: The Cornerstone

• Apply emollients liberally and regularly, even when eczema appears controlled - this is the foundation of all eczema management 1, 2, 3
• Apply emollients immediately after bathing while skin is still slightly damp to maximize hydration 1, 2
• The order of application (emollient before or after topical corticosteroid) does not matter - patients can apply in whichever order they prefer 4
• Use soap-free cleansers and avoid alcohol-containing products 2, 3
• Regular bathing is beneficial for cleansing and hydrating the skin 1

Topical Corticosteroids: The Mainstay

Topical corticosteroids are the primary active treatment for eczema and should not be withheld due to steroid phobia. 1, 2

Potency Selection Strategy

• For mild eczema: Start with mild-potency corticosteroids (hydrocortisone 1-2.5%) 3
• For moderate eczema: Use moderate-potency corticosteroids - these achieve treatment success in 52% versus 34% with mild potency 5
• For severe eczema: Use potent corticosteroids - these achieve treatment success in 70% versus 39% with mild potency 5
• Very potent corticosteroids show uncertain benefit over potent preparations and should be reserved for severe, refractory cases 5

Application Frequency

Apply topical corticosteroids once daily, not twice daily - once daily application is equally effective as twice daily for potent corticosteroids 2, 5, 6

This is a critical point where evidence contradicts older practice patterns. A Cochrane review of 15 trials with 1,821 participants found no difference in treatment success between once and twice daily application 5.

Duration and Stopping Strategy

• Apply until signs and symptoms (itching, rash, redness) resolve 7
• Implement "steroid holidays" - stop corticosteroids for short periods when possible 1, 2
• Do not apply more than twice daily maximum, as this increases side effects without improving efficacy 1, 3

Critical Safety Considerations

• Avoid very potent and potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is highest 2, 8
• Use the least potent preparation that maintains control 1, 2
• In children, monitor for pituitary-adrenal suppression with prolonged use of potent preparations 1

Managing Pruritus (Itching)

Use sedating antihistamines at nighttime only for severe pruritus during flares - their benefit comes from sedation, not direct anti-pruritic effects 1, 2, 3

• Non-sedating antihistamines have no value in eczema and should not be used 1, 3, 6
• Sedating antihistamines should be used short-term only as adjuvant therapy during relapses 1
• Avoid daytime use to prevent sedation 1, 3
• Be aware of tachyphylaxis with prolonged use 1

Managing Secondary Bacterial Infection

Continue topical corticosteroids when treating bacterial infection with appropriate systemic antibiotics - do not withhold corticosteroids when infection is present 2

• Watch for signs of infection: increased crusting, weeping, pustules 2, 8
• Flucloxacillin is first-line for Staphylococcus aureus (the most common pathogen) 1, 2
• Use phenoxymethylpenicillin if β-hemolytic streptococci are isolated 1
• Use erythromycin for flucloxacillin resistance or penicillin allergy 1

Eczema Herpeticum: A Medical Emergency

If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum and initiate treatment immediately. 2, 8

• Start oral acyclovir early in the disease course 1, 2
• In ill, feverish patients, give acyclovir intravenously 1, 2, 8

Lifestyle and Trigger Avoidance

• Keep nails short to minimize scratch damage 1, 3
• Avoid irritant clothing (wool) next to skin; recommend cotton clothing 1
• Avoid extremes of temperature 1

Common Pitfalls to Avoid

Steroid phobia leads to undertreatment - take time to explain different potencies and the benefits versus risks of topical corticosteroids 1, 2

• Do not withhold topical corticosteroids when infection is present - continue them alongside appropriate antibiotics 2
• Do not use topical corticosteroids continuously without breaks 2, 3
• Do not apply corticosteroids more than twice daily (once daily is sufficient for potent preparations) 1, 5, 6
• Do not use non-sedating antihistamines for eczema - they provide no benefit 1, 3, 6

When to Consider Second-Line Treatments

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks 2, 8
• Consider topical calcineurin inhibitors (pimecrolimus, tacrolimus) for sensitive sites or as corticosteroid-sparing agents after first-line treatments have been tried 7, 6
• Pimecrolimus is approved for patients age 2 years and older, used short-term with breaks between treatments 7
• Do not use topical calcineurin inhibitors in children under 2 years old 7

Proactive (Weekend) Therapy to Prevent Relapses

Once initial control is achieved, apply topical corticosteroids twice weekly (e.g., weekends) to previously affected areas to prevent flare-ups - this reduces relapse from 58% to 25% 2, 5

This "get control then keep control" strategy is supported by moderate-certainty evidence from 7 trials with 1,149 participants 5, 6.