What are the recommended interventions for a patient with eczema?

Recommended Interventions for Eczema

Apply potent or moderate-potency topical corticosteroids once daily as first-line treatment for eczema flare-ups, combined with liberal emollient use, as this approach provides the best balance of efficacy and safety. 1, 2, 3

First-Line Treatment: Topical Corticosteroids

Potency Selection Based on Severity

• For moderate to severe eczema, start with potent topical corticosteroids (such as clobetasol propionate 0.05% or mometasone furoate), as they are significantly more effective than mild-potency steroids, achieving treatment success in 70% versus 39% of patients 2, 3
• For mild eczema, moderate-potency topical corticosteroids are appropriate, achieving treatment success in 52% versus 34% with mild-potency steroids 3
• Use the least potent preparation that controls symptoms, but do not undertreate due to steroid fears 4, 1

Application Frequency and Duration

• Apply topical corticosteroids once daily, not twice daily - there is no additional benefit from more frequent application of potent steroids (OR 0.97,95% CI 0.68 to 1.38) 3, 5
• Apply to affected areas only, not to normal-appearing skin during acute flare treatment 1, 6
• Stop when signs and symptoms (itching, rash, redness) resolve, typically within 2-6 weeks 1, 6
• Implement "steroid holidays" when possible to minimize side effects 1

Site-Specific Cautions

• Avoid very potent or potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is higher 1
• Hands and feet tolerate higher potency steroids better due to thicker stratum corneum 7

Essential Adjunctive Therapy: Emollients

• Apply emollients liberally and frequently throughout the day, even when eczema appears controlled - this is the cornerstone of maintenance therapy 1, 7
• Apply immediately after bathing to damp skin to provide a surface lipid film that retards water loss 1, 7
• Use soap-free cleansers exclusively and avoid hot water, as these remove natural skin lipids 1, 7
• If using both emollients and topical corticosteroids, apply emollients after the corticosteroid 1

Proactive (Weekend) Therapy to Prevent Relapses

After achieving control of a flare, apply topical corticosteroids twice weekly (e.g., weekends) to previously affected areas to prevent relapse, while continuing daily emollients to unaffected skin 1, 8

• This proactive approach reduces relapse rates from 58% to 25% (RR 0.43,95% CI 0.32 to 0.57) over 16-20 weeks 3
• This strategy targets the subclinical inflammation that persists in normal-appearing skin after visible lesions clear 8

Managing Pruritus

• Prescribe sedating antihistamines (such as diphenhydramine) exclusively at nighttime for severe itching - their benefit comes from sedation allowing sleep, not direct anti-pruritic effects 1, 7
• Do not use non-sedating antihistamines - they have no value in atopic eczema 1, 5

Managing Secondary Bacterial Infection

• Watch for increased crusting, weeping, or pustules indicating Staphylococcus aureus infection 1, 7
• Add oral flucloxacillin as first-line antibiotic while continuing topical corticosteroids - do not delay or withhold corticosteroids when infection is present 1, 7
• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum (a medical emergency) 1
• Initiate oral acyclovir early; use intravenous acyclovir in ill, feverish patients 1

Second-Line Treatments for Moderate-to-Severe Disease

Topical Calcineurin Inhibitors

• Consider pimecrolimus 1% or tacrolimus 0.1% for sensitive sites (face, neck, flexures) where corticosteroid atrophy risk is high 5
• Tacrolimus 0.1% ranks among the most effective treatments, comparable to potent topical corticosteroids 2, 9
• Warning: Do not use in children under 2 years old 6
• Use only for short periods with breaks in between, as long-term safety is unknown and rare cases of cancer (skin or lymphoma) have been reported, though causality is unproven 6
• Most common side effect is burning or warmth at application site (usually mild-moderate, occurring in first 5 days, resolving within a week) 6

JAK Inhibitors

• Ruxolitinib 1.5% and delgocitinib 0.5% or 0.25% rank among the most effective treatments, comparable to potent/very potent topical corticosteroids 2, 9
• These are newer options for patients failing conventional therapy 2

Phototherapy

• Narrow-band ultraviolet B (312 nm) is an option for widespread disease not responding to topical therapy 4, 1
• Some concern exists about long-term adverse effects including premature skin aging and cutaneous malignancies, particularly with PUVA 4, 1

Systemic Therapy for Severe Disease

• Systemic corticosteroids have a limited but definite role only for acute severe flares requiring rapid control after exhausting all other options 1
• Never use for maintenance treatment - only to "tide over" during crisis periods 1
• Pituitary-adrenal suppression is a significant risk with prolonged use 1

Treatments to AVOID

• Do not use oral antihistamines (sedating or non-sedating) expecting direct anti-pruritic benefit - they do not work for eczema itch 5
• Do not use oral or topical antistaphylococcal treatments for infected eczema without appropriate systemic antibiotics - evidence does not support their routine use 5
• Do not use probiotics - they have not been shown to benefit eczema treatment 5
• Do not use emollient bath additives, silk clothing, or ion-exchange water softeners - large trials show no benefit 5
• Do not apply emollients from birth to prevent eczema - this may increase skin infections and food allergy 5

Safety Profile of Topical Corticosteroids

• Short-term use (median 3 weeks, range 1-16 weeks) of any potency topical corticosteroid does not increase skin thinning risk (low-certainty evidence from 25 trials with only 36 events among 3691 participants) 2, 3
• Abnormal skin thinning occurred in only 1% of participants across trials testing flare treatment strategies, mostly with very potent steroids (16 cases with very potent, 6 with potent, 2 with moderate, 2 with mild) 3
• Longer-term use (6-60 months) does increase skin thinning risk - 6 of 2044 participants (0.3%) developed thinning with mild to potent topical corticosteroids 2, 3

When to Refer to Specialist

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks 1, 7
• Need for systemic therapy or phototherapy 1, 7
• Suspected eczema herpeticum (medical emergency requiring immediate treatment) 1
• Diagnostic uncertainty or atypical presentation 1

Common Pitfalls to Avoid

• Undertreatment due to patient/parent steroid fears - explain different potencies and that short-term use is safe 1, 3
• Applying topical corticosteroids twice daily when once daily is equally effective - this wastes medication and increases cost 3, 5
• Withholding topical corticosteroids when infection is present - continue them while adding appropriate systemic antibiotics 1, 7
• Using continuous topical corticosteroids without breaks - implement steroid holidays and consider proactive (weekend) therapy instead 1