Best Initial Treatment for Eczema Exacerbated by Cold Weather
Start with a topical corticosteroid (at least moderate potency) applied once daily to affected areas, combined with liberal and frequent application of emollients, particularly immediately after bathing. 1, 2
Topical Corticosteroid Selection
Use moderate-potency topical corticosteroids as your first-line prescription for eczema flare-ups triggered by cold weather, as they are significantly more effective than mild-potency preparations (52% vs 34% treatment success rate) 3, 4
Potent topical corticosteroids are even more effective than moderate preparations (70% vs 39% treatment success), particularly for moderate-to-severe eczema 3, 4
Apply once daily—this is equally effective as twice-daily application for potent corticosteroids, making it simpler for patient adherence 4
Avoid very potent corticosteroids initially, as there is insufficient evidence they provide additional benefit over potent preparations, and they carry higher risk of skin thinning 3, 4
Essential Emollient Therapy
Prescribe liberal amounts of emollients to be applied regularly throughout the day, as this is the cornerstone of maintenance therapy and helps restore the skin barrier disrupted by cold, dry weather 2, 5, 6
Instruct patients to apply emollients immediately after bathing to provide a surface lipid film that prevents water loss 2
Replace regular soaps with soap-free cleansers or dispersible creams as soap substitutes, since soaps remove natural skin lipids and worsen dryness 1, 5
Treatment Duration and Monitoring
Continue topical corticosteroids until the flare resolves, typically 2-6 weeks for initial treatment 4
Implement short "steroid holidays" when possible to minimize side effects, particularly with potent preparations 2
If the patient fails to respond after 4 weeks of moderate-potency topical corticosteroids, this indicates need for escalation or specialist referral 2
Managing Pruritus
Only prescribe sedating antihistamines if severe nighttime itching is disrupting sleep—use them exclusively at bedtime as short-term adjuvant therapy during flares 1, 2
Do not prescribe non-sedating antihistamines, as they have little to no value in atopic eczema 1, 2, 5, 6
The benefit of sedating antihistamines comes from their sedative properties allowing patients to sleep through pruritus, not from histamine blockade 1, 2
Watch for Secondary Bacterial Infection
Monitor for signs requiring oral antibiotics: increased crusting, weeping, pustules, or failure to respond to topical treatment 1, 2
Prescribe flucloxacillin as first-line oral antibiotic if secondary Staphylococcus aureus infection develops 1, 2, 5
Do not stop topical corticosteroids when infection is present—continue them alongside appropriate systemic antibiotics 2
Common Pitfalls to Avoid
Do not prescribe oral corticosteroids for cold weather eczema flares—they should never be used for maintenance treatment and are reserved only for severe refractory cases after exhausting all other options 1, 2, 7
Avoid using very potent or potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is higher 2
Address patient fears about topical corticosteroids causing harm—explain that short-term use (median 3 weeks) shows no evidence of increased skin thinning, and abnormal thinning occurs in only 1% of cases, mostly with very potent preparations 4
Long-Term Prevention Strategy
Once the acute flare is controlled, consider weekend (proactive) therapy with topical corticosteroids applied twice weekly to previously affected areas to prevent relapses—this reduces flare risk from 58% to 25% 4
Emphasize continued daily emollient use even when skin appears controlled 2, 6
Advise avoiding temperature extremes and wearing cotton clothing next to skin rather than wool 1