What are the treatment options for eczema?

Eczema Treatment

First-Line Treatment: Topical Corticosteroids and Emollients

Topical corticosteroids are the mainstay of treatment for atopic eczema and should be used as first-line therapy, applying the least potent preparation required to keep the eczema under control. 1

Topical Corticosteroid Application

• Apply topical corticosteroids no more than twice daily to affected areas 2, 1
• Use the least potent preparation that achieves adequate control 2, 1
• Very potent and potent corticosteroids should be used with caution for limited periods only 2, 1
• Implement short "steroid holidays" when the eczema is controlled to minimize side effects including pituitary-adrenal suppression 1
• Once-daily application is as effective as twice-daily application and should be preferred 3

Emollient Therapy (Essential Foundation)

• Apply emollients liberally and regularly, even when eczema appears controlled—this is the cornerstone of maintenance therapy 1
• Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss 2, 1
• Use soap-free cleansers (dispersible cream as soap substitute) and avoid alcohol-containing products 2, 1
• Regular bathing for cleansing and hydrating the skin is recommended 2, 1

Lifestyle Modifications

• Keep nails short to minimize damage from scratching 2
• Avoid extremes of temperature 2
• Avoid irritant clothing such as wool next to the skin; cotton clothing is preferred 2

Managing Pruritus

Sedating antihistamines may help with nighttime itching through their sedative properties, not through direct anti-pruritic effects. 1

• Use sedating antihistamines only as short-term adjuvant therapy during severe pruritus, primarily for nighttime use 2, 1
• Large doses may be required in children 2
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used 2, 1, 4
• Avoid daytime use of sedating antihistamines 2

Managing Secondary Infections

Bacterial Infections

Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently. 1

• Watch for signs of secondary bacterial infection: increased crusting, weeping, pustules, or failure to respond to treatment 2, 1
• Flucloxacillin is the first-line oral antibiotic for Staphylococcus aureus, the most common pathogen 2, 1
• Phenoxymethylpenicillin should be given if β-hemolytic streptococci are isolated 2
• Erythromycin may be used when there is resistance to flucloxacillin or in patients with penicillin allergy 2
• Topical or oral antistaphylococcal treatments for infected eczema lack evidence and should be avoided 3

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

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

Second-Line Treatments for Sensitive Areas

Topical calcineurin inhibitors (tacrolimus, pimecrolimus) are useful for sensitive sites including the face, neck, and periocular areas where corticosteroid-related atrophy risk is higher. 3, 4

• Apply tacrolimus 0.03% ointment twice daily to affected skin on sensitive areas 5
• Tacrolimus can be used in conjunction with topical corticosteroids as first-line treatment 4
• Avoid tacrolimus in patients with history of herpes simplex virus or varicella zoster virus 5

Systemic Therapy for Severe Disease

When to Consider Systemic Treatment

Systemic immunosuppressive agents should be considered for patients with atopic eczema in whom disease activity cannot be controlled adequately with topical treatments. 6

Cyclosporine (First-Line Systemic Agent)

Cyclosporine is recommended as the first option for patients with atopic eczema refractory to conventional treatment, with consistent evidence of effectiveness from eleven studies. 6

Dupilumab (Most Effective Biological)

Dupilumab is the most effective biological treatment for moderate to severe eczema, achieving EASI75 improvement 3 times more often than placebo (RR 3.04,95% CI 2.51-3.69) at short-term follow-up. 7

• Dupilumab also significantly improves POEM scores (mean difference 7.30,95% CI 6.61-8.00) 7
• Low to moderate-certainty evidence indicates a lower proportion of participants with serious adverse events compared to placebo 7
• Dupilumab is associated with specific adverse events including eye inflammation and eosinophilia 7

Other Systemic Options

• Evidence from randomized controlled trials exists for interferon-γ and azathioprine 6
• Mycophenolate mofetil showed effectiveness in two small uncontrolled studies 6
• Tralokinumab may be more effective than placebo in achieving short-term EASI75 (RR 2.54,95% CI 1.21-5.34), but evidence is low certainty 7

Phototherapy

• Narrow band ultraviolet B (312 nm) is an option for moderate to severe atopic dermatitis when first-line treatments are inadequate 2, 4
• Some concern exists about long-term adverse effects such as premature skin aging and cutaneous malignancies, particularly with PUVA 2

Oral Corticosteroids (Use with Extreme Caution)

Systemic corticosteroids have a limited but definite role only for tiding occasional patients with severe atopic eczema through acute crises, and should not be used for maintenance treatment. 2, 1

• The decision to use systemic steroids should never be taken lightly 2
• They should not be considered until all other avenues have been explored 2, 1
• Pituitary-adrenal suppression is a significant risk, particularly with prolonged use 1
• Systemic corticosteroids are not generally recommended for chronic eczematous dermatitis 8

Critical 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 1
• Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when disease is controlled 1
• Avoid very potent corticosteroids in thin-skinned areas (face, neck, flexures, genitals) where risk of atrophy is higher 5
• Patients' or parents' fears of steroids often lead to undertreatment—explain the different potencies and benefits/risks clearly 2, 1
• Do not use twice-daily corticosteroid application when once-daily is equally effective 3
• Do not prescribe non-sedating antihistamines for eczema as they have no value 2, 1, 4
• Do not use probiotics, silk clothing, ion-exchange water softeners, or emollient bath additives as they lack evidence of benefit 3

When to Refer to Specialist

• Failure to respond to moderate potency topical corticosteroids after 4 weeks 1
• Need for systemic therapy or phototherapy 1
• Suspected eczema herpeticum (medical emergency requiring immediate referral) 1
• Maximum waiting time for first specialist appointment should be six weeks 2