What are the treatment options for eczema (atopic dermatitis)?

Treatment of Eczema (Atopic Dermatitis)

Topical corticosteroids are the first-line treatment for eczema and should be applied no more than twice daily using the least potent preparation that controls symptoms, combined with liberal daily use of emollients as the cornerstone of maintenance therapy. 1

First-Line Treatment Strategy

Topical Corticosteroids

• Apply topical corticosteroids no more than twice daily to affected areas, using the least potent preparation that effectively controls the eczema 1
• Very potent and potent corticosteroids should be reserved for limited periods only, with short "steroid holidays" when possible to minimize side effects 1
• Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is higher 1
• A 2024 Cochrane network meta-analysis confirmed that potent topical steroids rank among the most effective treatments for both patient-reported symptoms and clinician-reported signs 2
• Short bursts (3 days) of potent corticosteroids are equally effective as prolonged use (7 days) of mild preparations for mild-to-moderate eczema 3

Essential Emollient Therapy

• Liberal use of emollients is mandatory for maintenance therapy and should be applied regularly, even when eczema appears controlled 1
• Apply emollients after bathing to provide a surface lipid film that retards water loss 1
• Use soap-free cleansers and avoid alcohol-containing products 1
• Regular bathing for cleansing and hydrating the skin is recommended 1

Managing Pruritus

• Sedating antihistamines may help with nighttime itching through their sedative properties, not through direct anti-pruritic effects 1
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used 1

Managing Secondary Infections

Bacterial Infections

• Watch for signs of secondary bacterial infection: increased crusting, weeping, or pustules 1
• Flucloxacillin is the first-line oral antibiotic for Staphylococcus aureus, the most common pathogen 1
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not delay or withhold steroids 1
• Use erythromycin in penicillin-allergic patients 4

Eczema Herpeticum (Medical Emergency)

• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum—this is a medical emergency 1, 5
• For ill, feverish patients, administer intravenous acyclovir immediately 5
• Initiate oral acyclovir early in the disease course for non-febrile patients 1, 5

Advanced Therapies for Moderate-to-Severe Disease

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% and pimecrolimus are effective second-line treatments, particularly useful where prolonged steroid use is concerning 4, 6
• The 2024 Cochrane review ranked tacrolimus 0.1% among the most effective treatments 2
• Local application site reactions are most common with tacrolimus 0.1% (moderate confidence) 2

Biologic Therapy

• Dupilumab (DUPIXENT) is FDA-approved for moderate-to-severe atopic dermatitis in patients aged 6 months and older whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable 7
• Dupilumab can be used with or without topical corticosteroids 7
• Dupilumab works by blocking two proteins that contribute to inflammation in atopic dermatitis 7

JAK Inhibitors

• Ruxolitinib 1.5% and delgocitinib 0.5% or 0.25% were ranked among the most effective treatments in the 2024 Cochrane network meta-analysis 2

Phototherapy

• Narrowband ultraviolet B (312 nm) is an option for phototherapy 1
• Some concern exists about long-term adverse effects such as premature skin aging and cutaneous malignancies, particularly with PUVA 1

Systemic Corticosteroids (Use with Extreme Caution)

• Systemic corticosteroids should only be used in acute severe flares requiring rapid control when topical therapy has failed, for short-term "tiding over" during crisis periods, and only after exhausting all other options 1
• Oral steroids should not be used for maintenance treatment or to induce stable remission 1
• Pituitary-adrenal suppression is a significant risk, particularly with prolonged use 1
• Corticosteroid-related mortality has been documented in other inflammatory conditions 1

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 1
• Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when possible 1
• Patients' or parents' fears of steroids often lead to undertreatment—explain the different potencies and the benefits/risks clearly 1
• Skin thinning was not increased with short-term use of any topical steroid potency, but was reported in 0.3% of participants treated with longer-term (6-60 months) topical steroids 2

When to Refer or Escalate

• Failure to respond to moderate potency topical corticosteroids after 4 weeks 1
• Need for systemic therapy or phototherapy 1
• Suspected eczema herpeticum (medical emergency) 1