What is the first line of treatment for eczema (atopic dermatitis)?

First-Line Treatment for Eczema (Atopic Dermatitis)

The first-line treatment for eczema consists of liberal and frequent application of emollients for daily maintenance combined with mild-potency topical corticosteroids (1% hydrocortisone) applied to affected areas during flare-ups. 1, 2

Daily Maintenance Therapy

Emollient Application

• Apply emollients liberally and frequently to maintain skin hydration and improve barrier function 1, 2
• Emollients are most effective when applied immediately after bathing to lock in moisture and prevent dryness 1, 2
• Replace regular soaps with soap substitutes (dispersable creams) to prevent removal of natural skin lipids and reduce irritation 1, 2

Bathing Practices

• Daily bathing is beneficial for cleansing and hydrating the skin when followed immediately by emollient application 2
• Use soap-free cleansers rather than traditional soaps that strip natural oils 1, 3

Treatment of Flare-Ups

Topical Corticosteroid Selection

• Use mild-potency topical corticosteroids (1% hydrocortisone) as first-line treatment for flare-ups 1, 2, 4
• Apply the least potent preparation required to keep the eczema under control 5, 1
• For facial atopic dermatitis, mild-potency corticosteroids are particularly important since facial skin is thin and more susceptible to steroid-related side effects 2

Application Guidelines

• Apply topical corticosteroids not more than 3 to 4 times daily 4
• Treatment should not be applied more than twice daily in most cases, with some newer preparations requiring only once daily application 5
• Once daily application of potent topical corticosteroids is as effective as twice daily application 6
• Apply for limited periods until the flare resolves, then stop 1, 2

Potency Escalation When Needed

• If mild corticosteroids are insufficient for moderate to severe eczema, moderate-potency corticosteroids result in more participants achieving treatment success (52% vs 34% with mild potency) 6
• Potent topical corticosteroids result in even greater treatment success (70% vs 39% with mild potency) for moderate to severe disease 6, 7
• Very potent and potent corticosteroids should be used with caution for limited periods only due to increased risk of adverse effects 5

Managing Pruritus

• Antihistamines may be useful as a short-term adjuvant during severe flares with significant itching, primarily due to their sedative properties 5, 1, 2
• Use sedating antihistamines at nighttime to help with sleep disruption from itching 5
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used 5, 1, 2, 3
• Large doses of antihistamines may be required in children 5

Alternative First-Line Topical Agents

• Ichthammol (1% in zinc ointment) may be considered as an alternative topical treatment, particularly for lichenified eczema 5, 2
• Ichthammol is less irritant than coal tars and can be applied as an ointment or in paste bandages 5

Addressing Secondary Complications

Bacterial Infections

• Monitor for signs of secondary bacterial infection including crusting, weeping, and punched-out erosions 1, 2
• Flucloxacillin is the most appropriate antibiotic for treating Staphylococcus aureus, the most common pathogen 5, 1
• Phenoxymethylpenicillin should be given if β-hemolytic streptococci are isolated 5
• Erythromycin may be used when there is resistance to flucloxacillin or in patients with penicillin allergy 5

Viral Infections

• Eczema herpeticum (herpes simplex infection) may present as grouped, punched-out erosions or vesicles 2
• Eczema herpeticum responds to oral acyclovir, which should be given early in the course of disease 5, 1
• In ill, feverish patients, acyclovir should be given intravenously 5

Proactive Maintenance to Prevent Flares

• After initial flare control, apply topical anti-inflammatories 2-3 times weekly on previously affected areas to reduce the risk of flare development and lengthen time to relapse 2
• Both topical corticosteroids and calcineurin inhibitors have demonstrated efficacy when used in this proactive manner 2

Common Pitfalls and Caveats

Corticosteroid Safety

• Short-term use (median 3 weeks) of topical corticosteroids of any potency does not increase risk of skin thinning 6, 7
• Longer-term use (6-60 months) of mild to potent topical corticosteroids does show increased skin thinning compared to topical calcineurin inhibitors 7
• When possible, corticosteroids should be stopped for short periods to minimize long-term risks 5
• Infants are particularly susceptible to side effects from topical corticosteroids due to their high body surface area to volume ratio 1

Application Site Reactions

• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) cause more application-site reactions than topical corticosteroids 7, 8
• Crisaborole 2% also causes increased application-site reactions compared to topical corticosteroids 7, 8

Indications for Specialist Referral

• Failure to respond to first-line treatment 5, 1, 2
• Diagnostic uncertainty 1, 2
• When second-line treatments are being considered 1, 2
• Most people with eczema will respond well to first-line management and do not require referral to a specialist 5