What is the recommended treatment for a patient with eczema (atopic dermatitis)?

Treatment of Eczema (Atopic Dermatitis)

Start with topical corticosteroids as first-line therapy, using the least potent preparation that controls symptoms, applied no more than twice daily to affected areas, combined with liberal emollient use as the cornerstone of maintenance therapy. 1

Topical Corticosteroid Selection by Potency

Choosing the Right Potency

• Use mild potency (1% hydrocortisone) for facial, neck, flexural, and genital areas where skin is thin and atrophy risk is highest 2, 3
• Use moderate potency topical corticosteroids for body areas in mild-to-moderate eczema, as they are probably more effective than mild preparations (52% vs 34% treatment success) 4, 5
• Use potent topical corticosteroids for moderate-to-severe eczema on body areas, as they probably result in large increases in treatment success (70% vs 39% compared to mild potency) 4, 5
• Reserve very potent corticosteroids for severe flares on thick-skinned areas only, using them for limited periods with short "steroid holidays" when possible 1
• Avoid very potent or potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) due to extremely high atrophy risk 1, 2

Application Frequency

• Apply topical corticosteroids once daily rather than twice daily, as once-daily application of potent topical corticosteroids probably does not decrease treatment success compared to twice-daily use (moderate-certainty evidence from 15 trials with 1821 participants) 5
• Maximum application frequency should not exceed twice daily 1

Duration and Steroid Holidays

• Implement "steroid holidays"—stop corticosteroids for short periods once symptoms improve to minimize pituitary-adrenal suppression and local side effects 1, 2
• Use very potent and potent corticosteroids with caution for limited periods only 1

Essential Emollient Therapy

• Apply emollients liberally and regularly to all affected areas, even when eczema appears controlled, as this is the cornerstone of maintenance therapy 1, 2, 3, 6
• Apply emollients immediately after bathing to provide a surface lipid film that retards water loss from the epidermis 1, 2, 3
• Use soap-free cleansers instead of regular soap, which strips natural lipids and worsens the compromised skin barrier 1, 2, 3
• Regular bathing for cleansing and hydrating the skin is recommended 1
• Avoid alcohol-containing products 1, 3

Alternative First-Line Options: Topical Calcineurin Inhibitors

• Consider tacrolimus 0.1% or pimecrolimus 1% as alternatives to topical corticosteroids or in conjunction with them, particularly for facial eczema or when steroid side effects are a concern 6, 7
• Tacrolimus 0.1% ranks among the most effective treatments (similar to potent topical corticosteroids) with moderate confidence 4
• Tacrolimus and pimecrolimus bind to FK-binding protein, inhibiting calcineurin and preventing T-cell activation without suppressive effects on connective tissue 7
• Expect burning sensation and increased pruritus at application sites during the first days of treatment—this is the main adverse event but typically resolves 7, 4
• Tacrolimus 0.1% and pimecrolimus 1% are more likely to cause application-site reactions than topical corticosteroids (OR 2.2 and 1.44 respectively) but do not cause skin atrophy 4

Managing Pruritus

• Use sedating antihistamines (hydroxyzine, diphenhydramine) only for nighttime itching during severe flares, as they help through sedative properties, not direct anti-pruritic effects 1, 2, 3
• Do not use non-sedating antihistamines, as they have little to no value in atopic eczema 1

Managing Secondary Bacterial Infections

• Watch for signs of secondary bacterial infection: increased crusting, weeping, or pustules 1, 2, 3
• Prescribe oral flucloxacillin as first-line antibiotic for Staphylococcus aureus, the most common pathogen in infected eczema 1, 2, 3
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—infection is not a contraindication to topical steroid use 1, 2

Eczema Herpeticum: Medical Emergency

• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum and initiate treatment immediately 1, 3
• Initiate oral acyclovir early in the disease course 1
• In ill, feverish patients, administer acyclovir intravenously 1, 3
• Refer emergently 2

Proactive (Weekend) Therapy to Prevent Relapses

• Apply topical corticosteroids twice weekly (weekend therapy) to previously affected areas after initial control is achieved to prevent flare-ups 5
• Weekend (proactive) therapy probably results in large decrease in likelihood of relapse from 58% to 25% (RR 0.43, moderate-certainty evidence from 7 trials with 1149 participants) 5
• No cases of abnormal skin thinning were identified in seven trials assessing this strategy (1050 participants, low-certainty evidence) 5

Systemic Therapy for Moderate-to-Severe Disease

• Consider narrow band ultraviolet B (312 nm) phototherapy when first-line treatments are inadequate 1, 6
• Some concern exists about long-term adverse effects such as premature skin aging and cutaneous malignancies, particularly with PUVA 1
• Reserve systemic corticosteroids only for acute severe flares requiring rapid control when topical therapy has failed, for short-term "tiding over" during crisis periods 1
• Do not use oral steroids for maintenance treatment or to induce stable remission 1
• Pituitary-adrenal suppression is a significant risk with prolonged oral steroid use, and corticosteroid-related mortality has been documented in other inflammatory conditions 1

Newer Agents

• Dupilumab and crisaborole are effective but currently cost-prohibitive for most patients 6
• Crisaborole 2% is more likely to cause application-site reactions (OR 2.12, high confidence) 4
• JAK inhibitors (ruxolitinib 1.5%, delgocitinib 0.5%) rank among the most effective treatments with moderate confidence 4
• PDE-4 inhibitors (roflumilast 0.15%) rank among the least effective treatments 4

Critical Pitfalls to Avoid

• Do not delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given concurrently 1, 2
• Do not undertreat eczema due to steroid phobia—explain to patients that appropriate short-term use of low-potency steroids is safer than chronic undertreated inflammation 2
• Patients' or parents' fears of steroids often lead to undertreatment—explain the different potencies and the benefits/risks clearly 1
• Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when possible 1

Local Adverse Events: Skin Thinning

• Abnormal skin thinning occurred in only 26 cases from 2266 participants (1%) across 22 short-term trials (low-certainty evidence) 5
• Most cases were from higher-potency topical corticosteroids (16 with very potent, 6 with potent, 2 with moderate, 2 with mild) 5
• Short-term use (median 3 weeks, range 1-16 weeks) of mild, moderate, potent, or very potent topical corticosteroids showed no evidence for increased skin thinning (low confidence) 4
• Longer-term use (6-60 months) showed increased skin thinning with mild to potent topical corticosteroids versus topical calcineurin inhibitors (3 trials, 4069 participants, 6 events with topical corticosteroids) 4

When to Refer to Dermatology

• Failure to respond to moderate potency topical corticosteroids after 4 weeks of appropriate use 1, 2, 3
• Need for systemic therapy or phototherapy 1, 3
• Suspected eczema herpeticum (refer emergently) 1, 2