What is the recommended emollient and dosage for a patient with nummular eczema, including considerations for children and patients with persistent symptoms?

Emollient Management for Nummular Eczema

Apply emollients liberally and frequently—at least twice daily and immediately after bathing—as this is the cornerstone of treatment for nummular eczema, with patients requiring aggressive moisturization due to the co-existing severe skin dryness present in two-thirds of cases. 1

Emollient Selection and Application Frequency

Recommended Emollient Types

• Use ointments or thick creams rather than lotions for nummular eczema, as the thick, lichenified plaques characteristic of this condition require maximum occlusion and penetration 2
• Fragrance-free formulations are essential to avoid irritation and sensitization 2
• Urea-containing emollients (10-20%) are particularly effective for the hyperkeratotic, scaly plaques typical of nummular eczema, though urea concentrations ≥10% should be avoided in children under 1 year except on limited areas like palms and soles 2
• Recent evidence demonstrates that urea-glycerol combination creams significantly strengthen skin barrier function and reduce irritant sensitivity more effectively than simple paraffin-based emollients 3

Application Protocol

• Apply at least twice daily as a minimum, with more frequent application (up to 3-4 times daily) for moderate-to-severe cases 2, 4
• Apply immediately after bathing (within 3 minutes of patting skin dry) to trap moisture when skin is most hydrated 2, 1
• Continue aggressive emollient use even when lesions appear controlled, as this provides steroid-sparing effects and prevents relapse 1, 5
• For adults, expect to use 200-400 grams per week when applying twice daily to affected areas 2

Bathing Recommendations

• Use lukewarm water only and limit bathing to 10-15 minutes to prevent excessive drying 2, 1
• Replace all regular soaps with soap-free cleansers or emollient substitutes (such as aqueous cream, Doublebase gel, or emulsifying ointment), as soaps and detergents strip natural skin lipids and worsen the underlying xerosis 1, 6, 5

Age-Specific Considerations for Children

Infants and Young Children (Under 2 Years)

• Apply emollients at least twice daily, with the same frequency as adults 6
• Avoid urea concentrations ≥10% except for once-daily application to limited areas like palms and soles 2
• Use ointments or thick creams rather than lotions for maximum barrier protection 6

Older Children (2-12 Years)

• Apply emollients at least twice daily, increasing to 2-3 times daily for moderate-to-severe disease 4
• Urea-containing products (10-20%) can be used more liberally after age 2 years 2
• Parents of children with moderate-to-severe eczema prefer more frequent application schedules than those with mild disease 4

Integration with Topical Corticosteroids

For Nummular Eczema Specifically

• Apply moderate-to-potent topical corticosteroids once or twice daily to the coin-shaped lesions, as nummular plaques are thick and lichenified, requiring higher potency than mild eczema 1
• Continue emollients throughout corticosteroid treatment—they have documented steroid-sparing effects 2, 5
• Apply emollients at least 30 minutes before or after topical corticosteroids to avoid dilution 5

Maintenance After Clearance

• Implement proactive twice-weekly corticosteroid application (weekend therapy) to previously affected sites to prevent relapse, as nummular eczema has a chronic, relapsing course 1
• Never discontinue emollients even when lesions clear—this is critical for long-term control 1, 5

Adjunctive Measures for Persistent Symptoms

For Thick, Lichenified Nummular Plaques

• Consider ichthammol 1% in zinc ointment or coal tar solution 1% for particularly thick, chronic lesions that resist standard therapy 1
• Ichthammol paste bandages can be especially effective for the lichenified plaques typical of nummular eczema 1

Managing Secondary Infection

• Watch for increased crusting, weeping, or pustules—these indicate secondary bacterial infection with Staphylococcus aureus, which is common in nummular eczema 1, 6, 5
• Add oral flucloxacillin as first-line antibiotic while continuing topical corticosteroids 1, 6
• Do not delay or withhold topical corticosteroids when infection is present—they remain primary treatment when appropriate systemic antibiotics are given concurrently 1

Common Pitfalls to Avoid

• Do not use simple paraffin-based emollients alone—recent evidence shows they fail to improve skin barrier function and may actually reduce natural moisturizing factors 3
• Avoid hot water and excessive bathing duration, as this worsens xerosis 1, 6, 5
• Do not prescribe non-sedating antihistamines—they have no value in eczema management 1, 6
• Avoid alcohol-containing lotions or gels—use oil-in-water creams or ointments instead 5

When to Escalate Treatment

• Refer to dermatology if no improvement after 4 weeks of appropriate moderate-to-potent topical corticosteroids 1, 5
• Consider systemic therapy (methotrexate has demonstrated efficacy in children with severe nummular eczema refractory to topical therapy) 7
• Consider narrow-band UVB phototherapy (312 nm) for treatment-resistant cases 1