Do you prescribe steroid cream for eczema?

Topical Corticosteroids for Eczema Treatment

Yes, topical corticosteroids are the first-line treatment for eczema, with potency selection based on disease severity and anatomical location. 1, 2, 3

Potency Selection Algorithm

For facial and periocular eczema:

• Start with low-potency hydrocortisone 1% as first-line treatment 1
• For moderate-to-severe periocular disease, use preservative-free dexamethasone 0.1% for short-term use only (maximum 8 weeks) 1
• The thin skin in these areas increases risk of adverse effects, necessitating lower potency agents 1

For body eczema:

• Mild eczema: Use mild-potency topical corticosteroids 3
• Moderate eczema: Moderate-potency agents result in treatment success in 52% versus 34% with mild potency (OR 2.07) 4
• Severe or recalcitrant eczema: Potent topical corticosteroids achieve treatment success in 70% versus 39% with mild potency (OR 3.71) 4
• Very potent corticosteroids show uncertain benefit over potent agents and should be reserved for limited periods only 3, 4

Application Protocol

Frequency:

• Once daily application is equally effective as twice daily for potent topical corticosteroids 4
• More frequent application does not improve efficacy but increases side effect risk 3

Timing and technique:

• Apply after bathing when skin is slightly damp for better absorption 1
• Apply emollients at least 30 minutes before or after topical corticosteroids 1

Duration:

• Use short courses to control flares 1, 3
• Maximum 8 weeks for periocular moderate-to-severe disease requiring dexamethasone 1
• A 3-day burst of potent corticosteroid is as effective as 7 days of mild preparation for mild-to-moderate eczema 5

Proactive (Weekend) Therapy for Relapse Prevention

For patients with recurrent flares, weekend (proactive) therapy dramatically reduces relapse risk from 58% to 25% (RR 0.43) compared to reactive use only. 4 This involves applying topical corticosteroids twice weekly to previously affected areas even when clear. 4

Essential Adjunctive Measures

• Apply fragrance-free emollients liberally to entire body at least once daily to restore skin barrier function 2
• Use emollients as soap substitutes; avoid regular soaps and detergents as they strip natural lipids 1, 2, 3
• Keep nails short to minimize scratching damage 1, 3

Critical Pitfalls to Avoid

Secondary infection recognition:

• Broken skin, scabbing, and oozing indicate bacterial superinfection requiring oral flucloxacillin 2
• Multiple discrete vesicles and erosions suggest eczema herpeticum requiring oral acyclovir, not antibiotics 2
• Oral antibiotics are preferred over topical antibiotic/steroid combinations for overt infection 2

Antihistamine misuse:

• Sedating antihistamines only for severe pruritus short-term at night 1, 3
• Non-sedating antihistamines have little to no value in eczema and should be avoided 2, 3

Monitoring for Adverse Effects

• Monitor for skin atrophy, telangiectasia, or striae, particularly in periocular regions 1, 3
• Risk of pituitary-adrenal axis suppression with extensive use, especially in children 3
• In short-term trials, abnormal skin thinning occurred in only 1% of participants (26/2266), predominantly with higher-potency agents 4
• Seven trials assessing weekend proactive therapy found zero cases of abnormal skin thinning in 1050 participants 4

When to Escalate Care

• Refer to dermatology if no improvement after 4 weeks of appropriate treatment 1
• Consider steroid-sparing agents (tacrolimus ointment or ciclosporin drops) early to facilitate tapering of ocular corticosteroids 1
• For treatment-resistant periocular disease, combination treatment with topical corticosteroids, tacrolimus, and ciclosporin may be necessary 1
• Consider patch testing to identify contact allergens exacerbating the condition 1