Treatment of Eczema (Atopic Dermatitis)
First-Line Treatment: Topical Corticosteroids
Topical corticosteroids are the mainstay of treatment for eczema and should be initiated as first-line therapy, using the least potent preparation that achieves disease control. 1, 2
Selecting Corticosteroid Potency
For moderate-to-severe eczema, start with potent topical corticosteroids (such as betamethasone valerate 0.1%), which achieve treatment success in approximately 70% of patients compared to 39% with mild preparations 3, 4
For mild eczema, moderate-potency corticosteroids are appropriate, achieving treatment success in 52% versus 34% with mild preparations 3
Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) due to high risk of skin atrophy 2, 5
In children, use lower potencies due to increased risk of systemic absorption and potential growth interference 2, 5
Application Frequency and Duration
Apply topical corticosteroids once daily - this is equally effective as twice-daily application for potent preparations 2, 3
Use short bursts of 3-7 days to control flares, then implement "steroid holidays" when disease is controlled 1, 2, 6
A 3-day burst of potent corticosteroid is as effective as 7 days of mild preparation for controlling flares in children 6
Common Pitfall: Steroid Phobia
Patients' or parents' fears of steroids frequently lead to undertreatment - you must explain the different potencies and clarify that short-term use carries minimal risk 1, 2. The evidence shows no increased skin thinning with short-term use (median 3 weeks) of any potency 4.
Essential Adjunctive Measures: Emollients and Skin Care
Liberal emollient use is the cornerstone of maintenance therapy and must be continued even when eczema appears controlled. 2
Apply emollients immediately after bathing to provide a surface lipid film that prevents water loss 1, 2
Use soap-free cleansers (dispersible creams as soap substitutes) since soaps and detergents strip natural skin lipids 1, 2
Regular bathing is beneficial for both cleansing and hydrating the skin 1, 2
Practical Avoidance Measures
Keep nails short to minimize damage from scratching 1
Avoid extremes of temperature 1
Wear cotton clothing next to skin rather than wool or other irritants 1
Managing Pruritus (Itching)
Use sedating antihistamines only for short-term relief during severe flares - their benefit comes from sedation, not direct anti-pruritic effects 1, 2
Non-sedating antihistamines have no value in eczema and should not be prescribed 1, 2
Antihistamines may lose effectiveness over time due to tachyphylaxis 1
Managing Secondary Bacterial Infection
Continue topical corticosteroids when treating bacterial infection - they remain the primary treatment when appropriate systemic antibiotics are given concurrently. 2, 5
Recognizing and Treating Bacterial Infection
Watch for increased crusting, weeping, or pustules as signs of secondary Staphylococcus aureus infection 2, 5
Prescribe oral flucloxacillin as first-line antibiotic for S. aureus, the most common pathogen 1, 2, 5
Use phenoxymethylpenicillin if beta-hemolytic streptococci are isolated 1
Use erythromycin for penicillin allergy or flucloxacillin resistance 1
Eczema Herpeticum: Medical Emergency
If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum and initiate oral acyclovir immediately. 1, 2, 5
Proactive (Weekend) Therapy to Prevent Relapses
For patients with frequent flares, apply topical corticosteroids twice weekly (weekends) to previously affected areas to prevent relapse, even when skin appears clear. 3
This proactive approach reduces relapse rate from 58% to 25% over 16-20 weeks 3
No increased skin thinning was observed in trials lasting up to 20 weeks 3
Alternative Topical Anti-Inflammatory Agents
Topical Calcineurin Inhibitors (Second-Line)
For corticosteroid-refractory disease or steroid-sensitive areas (face, eyelids), use tacrolimus 0.03% or 0.1% ointment twice daily. 5, 4
Tacrolimus 0.1% is ranked among the most effective treatments, comparable to potent corticosteroids 4
Major drawback: application-site burning/stinging occurs frequently (odds ratio 2.2 for tacrolimus 0.1%) 4
Pimecrolimus 1% is less effective than tacrolimus and ranked among the least effective treatments 4
JAK Inhibitors
Ruxolitinib 1.5% cream is highly effective, ranked among the top treatments with treatment success rates comparable to very potent corticosteroids 4
- Delgocitinib 0.25% and 0.5% also show high efficacy 4
PDE-4 Inhibitors
Crisaborole 2% and roflumilast 0.15% are consistently ranked among the least effective treatments and should be reserved for mild disease or when other options are unsuitable 3, 4
- Crisaborole causes application-site reactions at similar rates to tacrolimus (odds ratio 2.12) 4
Coal Tar Preparations
Ichthammol 1% in zinc ointment or coal tar solution 1% can be used for lichenified eczema, though they are less cosmetically acceptable 1, 7
- One trial found 1% hydrocortisone equally effective as coal tar cream 7
What NOT to Do
Do not use systemic corticosteroids for maintenance treatment - they have a limited role only for acute severe flares requiring rapid control after all other options have failed 2, 8
Systemic corticosteroids carry significant risks including pituitary-adrenal suppression 1, 2
Up to 77% of steroid-related deaths in inflammatory conditions are attributed to systemic corticosteroid complications 2
Do not delay topical corticosteroids when infection is present - continue them alongside appropriate antibiotics 2, 5
Do not use continuous corticosteroids without breaks - implement treatment holidays when disease is controlled 1, 2, 5
When to Refer or Escalate
Failure to respond to moderate-potency topical corticosteroids after 4 weeks 2
Need for systemic therapy or phototherapy (narrow-band UVB 312 nm) 2
Periocular eczema in children under 7 years (refer to ophthalmology due to risk of visual development interference) 5
Moderate-to-severe eyelid disease requiring topical corticosteroids for more than 8 weeks 5