What is a recommended topical steroid for a 60-year-old male with eczema involving the flexural areas and chest?

Recommended Topical Steroid for Eczema Involving Flexural Areas and Chest in a 60-Year-Old Male

For flexural areas (skin folds), use a moderate-potency topical corticosteroid such as clobetasone butyrate 0.05% (Eumovate) applied once daily, and for the chest, use a potent topical corticosteroid such as betamethasone valerate 0.1% (Betnovate) or mometasone furoate 0.1% (Elocon) applied once daily. 1

Rationale for Potency Selection by Body Site

Flexural Areas (Skin Folds)

• Moderate-potency steroids are appropriate for flexural areas to minimize the risk of skin atrophy, which is higher in these thin-skinned, occluded areas 1
• Clobetasone butyrate 0.05% is specifically recommended for areas like the neck and other flexural sites where skin thinning is a concern 1
• Very potent steroids like clobetasol propionate 0.05% should be avoided on flexural areas due to increased risk of skin thinning 1

Chest Area

• Potent topical corticosteroids are appropriate for the chest, which has thicker skin that can tolerate higher potency 1
• Betamethasone valerate 0.1% (Betnovate) or mometasone furoate 0.1% (Elocon) are recommended potent options for body areas like the chest 1
• Potent topical corticosteroids are probably more effective than mild topical corticosteroids for moderate or severe eczema 2

Application Regimen

Initial Treatment Phase

• Apply topical corticosteroid once daily for one month 1
• Once daily application is as effective as twice daily application for potent topical corticosteroids (OR 0.97,95% CI 0.68 to 1.38) 2
• Apply after bathing when skin is slightly damp for better absorption 1

Maintenance Phase

• After initial month, apply on alternate days for one month 1
• Then reduce to twice weekly application to previously affected areas to prevent relapse 1
• Weekend (proactive) therapy with topical corticosteroids reduces relapse likelihood from 58% to 25% (RR 0.43,95% CI 0.32 to 0.57) 2

Essential Adjunctive Measures

Emollient Therapy

• Apply emollients regularly as soap substitutes and moisturizers throughout treatment 3, 1
• For the chest and flexural areas, 15-30g of cream/ointment should be sufficient for a two-week period 1
• Apply emollients at least 30 minutes before or after topical corticosteroids 1
• Use dispersible cream as a soap substitute instead of soaps and detergents, which remove natural lipids 3

Skin Care Measures

• Avoid frequent washing with hot water 3
• Avoid extremes of temperature 3
• Keep nails short to minimize damage from scratching 3
• Wear cotton clothing next to skin; avoid wool 3

Monitoring and Follow-Up

Assessment Timeline

• Assess response to treatment after 2-4 weeks 1
• If no improvement after 4 weeks of appropriate treatment, consider referral to a dermatologist 1

Signs of Infection

• Look for crusting, weeping, or grouped punched-out erosions, which suggest bacterial or viral infection 3
• If bacterial infection is suspected (Staphylococcus aureus), send swabs and consider adding topical or systemic antibiotics 3, 4
• Herpes simplex infection (eczema herpeticum) requires prompt treatment with oral acyclovir 3

Safety Considerations

Risk of Skin Thinning

• Short-term use (median 3 weeks) of potent topical corticosteroids shows no evidence of increased skin thinning (OR 0.96,95% CI 0.21 to 4.43) 2
• However, longer-term use (6-60 months) does show increased skin thinning risk 5
• Abnormal skin thinning occurred in only 1% of participants across trials, with most cases from very potent steroids 2
• The risk is particularly elevated in flexural areas, which is why moderate-potency steroids are preferred for these sites 1

Application-Site Reactions

• Topical corticosteroids are least likely to cause application-site reactions compared to other topical anti-inflammatory agents 5
• Tacrolimus and crisaborole have higher rates of application-site reactions (OR 2.2 and 2.12 respectively) 5

Common Pitfalls to Avoid

• Do not use very potent steroids on flexural areas due to high risk of skin atrophy 1
• Do not apply topical corticosteroids more than once daily for potent preparations, as this does not improve efficacy 2
• Do not discontinue emollients even when eczema is controlled, as they have a steroid-sparing effect 3, 1
• Do not use the same potency for all body sites—flexural areas require lower potency than trunk areas 1
• Be aware that only 17% of patients understand topical corticosteroid potency levels, so clear education is essential 6