What is the recommended treatment for eczema, specifically regarding topical creams?

Topical Corticosteroids as First-Line Treatment for Eczema

Topical corticosteroids are the first-line treatment for eczema, with selection based on disease severity and anatomical location—use the least potent preparation that controls symptoms, applying once or twice daily. 1

Selecting the Right Potency

Topical corticosteroids are classified into seven potency classes (Class I being very high potency like clobetasol propionate 0.05%, Class VII being low potency like hydrocortisone 1%). 1

Anatomical site determines potency selection:

• Low potency agents (Class VI-VII) for face, neck, genitals, and body folds 1
• Medium to high potency agents (Class III-V) for trunk and extremities 1
• Potent and moderate topical corticosteroids are more effective than mild preparations for moderate-to-severe eczema 2

The evidence shows potent topical corticosteroids result in a large increase in treatment success compared to mild-potency agents (70% versus 39% achieving cleared or marked improvement), while moderate-potency agents also show significant benefit over mild preparations (52% versus 34% success rate). 2

Application Frequency and Technique

Apply topical corticosteroids once daily—this is equally effective as twice daily application for potent preparations. 1, 2

• Most studies involved twice daily application, though once daily may be sufficient for potent topical corticosteroids 1
• Fifteen pooled trials (1821 participants) found no decrease in treatment success with once daily versus twice daily application of potent topical corticosteroids 2
• Apply to affected areas only, using the smallest amount needed to control symptoms 3

Regarding order of application with emollients:

• The order does not matter—apply emollient and topical corticosteroid in whichever sequence is preferred 4
• If using moisturizers, apply them after topical corticosteroids 3
• Emollients are most effective when applied after bathing 5, 1

Maintenance Therapy to Prevent Flares

For maintenance between flares, apply medium-potency topical corticosteroids twice weekly (weekend/proactive therapy) to reduce disease relapse. 1

• Patients treated with fluticasone propionate 0.05% cream twice weekly were 7.0 times less likely to have relapse compared to vehicle (95% CI: 3.0-16.7; P < .001) 1
• Weekend (proactive) therapy decreases likelihood of relapse from 58% to 25% 2
• This approach is significantly better than reactive use (applying only when flares occur) 2

Safety Profile and Side Effects

Short-term use of topical corticosteroids has a low risk of skin thinning, with only 26 cases identified among 2266 participants (1%) across 22 trials. 2

• Most cases of skin thinning occurred with higher-potency preparations (16 with very potent, 6 with potent, 2 with moderate, 2 with mild) 2
• Long-term intermittent use (up to 5 years) probably results in little to no difference in skin thinning when used to treat flares 6
• Only one episode of skin atrophy was reported in 1213 participants using mild/moderate potency topical corticosteroids over 5 years 6
• No cases of clinical adrenal insufficiency were reported in 75 patients using mild/moderate topical corticosteroids over 3 years 6
• Other potential side effects include telangiectasias and hypopigmentation, especially with prolonged use of higher potency steroids 1

Alternative Agents for Steroid-Concerned Patients

For patients concerned about topical corticosteroid side effects, consider tacrolimus 0.03% or 0.1% ointment, pimecrolimus 1% cream, crisaborole ointment, or ruxolitinib cream. 1

• Tacrolimus 0.1% and ruxolitinib 1.5% rank among the most effective treatments for improving patient-reported symptoms and clinician-reported signs 7
• Local application site reactions (burning, stinging) are most common with tacrolimus 0.1% and crisaborole 2%, and least common with topical steroids 7
• Pimecrolimus should not be used in patients with Netherton's Syndrome or conditions with potential for increased systemic absorption 3

Essential Adjunctive Measures

Address steroid phobia through patient education before considering systemic therapy—this is often the primary barrier to treatment adherence. 5

• Fear of topical corticosteroids and topical calcineurin inhibitors is prevalent among patients, caregivers, and health professionals 5
• Explain the different potencies and the benefits versus risks of topical corticosteroids 5
• Use the least potent preparation required to keep eczema under control, and when possible, stop corticosteroids for short periods 5

Avoid irritants and optimize skin care:

• Use dispersible cream as a soap substitute instead of regular soaps and detergents, which remove natural lipids 5
• Avoid extremes of temperature, keep nails short, and avoid irritant clothing like wool next to skin 5
• Cotton clothing is more comfortable and recommended 5
• Bathing is useful for cleansing and hydrating skin—patients should decide on the most suitable bathing regimen 5

When to Escalate to Systemic Therapy

Consider systemic therapy only after documented failure of intensive topical therapy (medium-to-high potency topical anti-inflammatory therapy for 1-4 weeks) despite adequate patient education and adherence optimization. 5

• Document severe, extensive disease and/or quality of life impairment at several time points with adequate topical therapy 5
• Ascertain whether failure is due to disease severity (lack of efficacy) or lack of adherence 5
• If failure is due to lack of adherence or steroid phobia, first-line intervention is patient education 5
• Consider wet wrap therapy and soak-and-seal techniques before escalating 5