What are the treatment options for eczema?

Treatment Options for Eczema

First-Line Treatment: Topical Corticosteroids

Topical corticosteroids are the mainstay of eczema treatment and should be used as first-line therapy, applying the least potent preparation that controls symptoms no more than twice daily to affected areas. 1

Choosing Corticosteroid Potency

• For moderate-to-severe eczema, use potent or moderate-potency topical corticosteroids as they achieve treatment success in 70% versus 39% with mild potency (moderate-certainty evidence) 2
• For mild eczema, start with mild-potency corticosteroids, which achieve 34% treatment success rates 2
• Very potent corticosteroids show uncertain additional benefit over potent preparations and should be reserved for severe, refractory cases 2, 3
• Avoid very potent or potent corticosteroids on thin-skinned areas (face, neck, eyelids, flexures, genitals) where atrophy risk is highest 1, 4

Application Frequency

• Apply topical corticosteroids once daily - this is equally effective as twice-daily application for potent corticosteroids (moderate-certainty evidence) 2
• Once-daily application achieves similar treatment success rates as more frequent dosing while potentially reducing total steroid exposure 2

Duration and Steroid Holidays

• Use very potent and potent corticosteroids for limited periods only 1
• Implement short "steroid holidays" when disease is controlled to minimize side effects including pituitary-adrenal suppression 1, 4
• Stop corticosteroids when signs and symptoms (itching, rash, redness) resolve, or as directed 5
• Short bursts (3 days) of potent corticosteroids are as effective as 7 days of mild preparations for mild-to-moderate eczema 6

Essential Adjunctive Therapy: Emollients

• Apply emollients liberally and regularly, even when eczema appears controlled - this is the cornerstone of maintenance therapy 1, 4
• Apply emollients after bathing to provide a surface lipid film that retards water loss 1, 7
• Use soap-free cleansers and avoid alcohol-containing products 1, 4, 7
• Regular bathing for cleansing and hydrating is beneficial 1, 7

Second-Line Treatment: Topical Calcineurin Inhibitors

For eczema refractory to topical corticosteroids or when long-term treatment is needed (especially on sensitive areas), use tacrolimus or pimecrolimus. 4, 3

Tacrolimus

• Tacrolimus 0.1% ranks among the most effective treatments, comparable to potent corticosteroids for patient symptoms and clinician signs (moderate-certainty evidence) 3, 8
• For children aged 2-17 years or sensitive areas like eyelids, use tacrolimus 0.03% 4, 5
• Most common side effect is application-site burning or warmth, typically mild-to-moderate, occurring in first 5 days and resolving within one week 5, 8
• Do not use in children under 2 years old 5
• Avoid in patients with history of ocular herpes simplex or varicella zoster 4

Pimecrolimus

• Pimecrolimus 1% (Elidel) is approved for short-term and intermittent long-term use in patients ≥2 years 5
• Less effective than tacrolimus 0.1% and potent corticosteroids but causes fewer application-site reactions than tacrolimus 8
• Use only after other prescription medicines have not worked 5

Important Safety Considerations for Calcineurin Inhibitors

• Do not use continuously for long periods - use short-term with treatment breaks 5
• Apply only to areas with active eczema 5
• Limit sun exposure and avoid tanning beds/UV therapy during treatment 5
• A very small number of users have developed cancer (skin or lymphoma), though causation is not established 5

Third-Line Treatment: JAK Inhibitors and PDE-4 Inhibitors

JAK Inhibitors

• Ruxolitinib 1.5% ranks among the most effective treatments (OR 9.34 for treatment success), comparable to potent corticosteroids and tacrolimus 0.1% (moderate-certainty evidence) 3, 8
• Delgocitinib 0.5% and 0.25% also show high effectiveness rankings 3, 8

PDE-4 Inhibitors

• Crisaborole 2% and roflumilast 0.15% are available but rank among the least effective topical anti-inflammatory treatments 3, 8
• Crisaborole 2% causes frequent application-site reactions (high-certainty evidence) 8

Proactive (Weekend) Therapy to Prevent Flares

For patients with frequent relapses, apply topical corticosteroids twice weekly to previously affected areas to prevent flare-ups. 1

• Weekend (proactive) therapy reduces relapse likelihood from 58% to 25% (moderate-certainty evidence) 2
• Continue this regimen for 16-20 weeks or longer as needed 2
• No cases of skin thinning were reported in studies up to 5 years using this approach 2, 9

Managing Pruritus

• Use sedating antihistamines at nighttime only for severe itching during flares - they work through sedation, not direct anti-pruritic effects 1, 7
• Non-sedating antihistamines have no value in atopic eczema and should not be used 1, 7
• Avoid daytime use of sedating antihistamines 7

Managing Secondary Bacterial Infection

Do not delay or withhold topical corticosteroids when infection is present - continue them alongside appropriate antibiotics. 1, 4

• Watch for increased crusting, weeping, or pustules indicating bacterial superinfection 1, 4, 7
• Prescribe oral flucloxacillin for Staphylococcus aureus, the most common pathogen 1, 4, 7
• Use erythromycin for penicillin allergy 7

Managing Eczema Herpeticum (Medical Emergency)

• Suspect eczema herpeticum if you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever 1, 4
• Initiate oral acyclovir immediately - this is a medical emergency 1, 4, 7
• Administer IV acyclovir in ill, feverish patients 1
• Refer immediately to hospital 4

Systemic Therapy for Severe Disease

• Reserve oral corticosteroids only for acute severe flares requiring rapid control after all other options have failed 1
• Use only for short-term "tiding over" during crisis periods, never for maintenance 1
• Significant risks include pituitary-adrenal suppression and corticosteroid-related mortality 1
• Narrow-band UVB phototherapy (312 nm) is an option for moderate-to-severe disease 1

Local Adverse Effects: Skin Thinning

• Short-term use (1-16 weeks) of any corticosteroid potency shows no evidence of increased skin thinning (low-certainty evidence) 8
• Only 1 case of skin atrophy occurred in 1213 participants using mild/moderate potency over 5 years with intermittent use 9
• Longer-term use (6-60 months) shows 0.3% incidence of skin thinning (6/2044 participants) 3
• Risk increases with higher potency preparations 2

When to Refer or Escalate

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks 1
• Symptoms not improving after 6 weeks of treatment 5
• Need for systemic therapy or phototherapy 1
• Suspected eczema herpeticum 1, 4
• Children under 7 years with periocular eczema (due to risk of visual development interference) 4
• Treatment-resistant disease despite optimized topical therapy 4

Critical Pitfalls to Avoid

• Patients' or parents' steroid phobia often leads to undertreatment - explain different potencies and benefits/risks clearly 1
• Do not use topical corticosteroids continuously without breaks 1, 4
• Do not apply to wet skin immediately after bathing - dry skin first, then apply 4
• Do not cover treated areas with occlusive bandages or wraps (normal clothing is acceptable) 5
• Do not use in eyes - rinse with cold water if accidental exposure occurs 5