What is the best step in managing and curing eczema?

Best Step in Eczema Management

The best step in managing eczema is implementing first-line treatment with topical corticosteroids as the mainstay therapy, combined with aggressive emollient use and patient education—most patients will achieve control with this approach and eczema cannot be cured, only controlled. 1, 2

Understanding That Eczema Cannot Be Cured

• Eczema is a chronic, relapsing inflammatory skin condition that cannot currently be prevented or cured—the goal is disease control, reducing symptoms, and improving quality of life. 3
• Most people with eczema will respond well to first-line management and do not require specialist referral. 1

First-Line Treatment: The Foundation

Topical Corticosteroids as Primary Therapy

Use topical corticosteroids as the mainstay of treatment, applying the least potent preparation that controls the eczema, with application no more than twice daily. 1, 2, 4

• For mild eczema in children, start with mildly potent steroids; for adults or more severe disease, use moderately potent steroids. 1
• Very potent and potent corticosteroids should be used with caution for limited periods only, particularly avoiding continuous use without breaks. 1, 2
• Implement "steroid holidays" (short breaks) when possible to minimize side effects, especially the risk of pituitary-adrenal suppression in children. 1, 2
• The effectiveness of topical steroids can be enhanced by using occlusive dressings or films when appropriate. 1

Common pitfall: Patients and parents often undertreated due to steroid fears—explain the different potencies, benefits, and actual risks clearly to ensure adherence. 1, 2

Essential Emollient Therapy

Apply emollients liberally and frequently throughout the day, immediately after bathing (within 3 minutes), as this is the cornerstone of maintenance therapy even when eczema appears controlled. 1, 5, 2

• Use soap-free cleansers exclusively and avoid hot water, as soaps remove natural skin lipids and worsen dry skin. 1, 5
• Bathing is useful for cleansing and hydrating skin—patients should use dispersible cream as a soap substitute. 1
• Emollients provide a surface lipid film that retards evaporative water loss from the epidermis and are most effective when applied after bathing. 1, 5

Patient Education: Critical for Success

Adequate time for explanation and demonstration is essential—have a nurse demonstrate how to apply treatments and provide written information. 1

• Educate about avoiding aggravating factors such as irritants, extremes of temperature, and wool clothing worn next to skin (cotton is preferred). 1
• Keep nails short to minimize damage from scratching. 1

Managing Complications

Secondary Bacterial Infection

Watch for crusting, weeping, or pustules indicating Staphylococcus aureus infection—add oral flucloxacillin while continuing topical corticosteroids. 1, 2

• Do not delay or withhold topical corticosteroids when infection is present—they remain primary treatment when appropriate systemic antibiotics are given concurrently. 2
• Erythromycin may be used when there is resistance to flucloxacillin or in patients with penicillin allergy. 1

Eczema Herpeticum (Medical Emergency)

If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum and initiate oral acyclovir early. 1, 2

• In ill, feverish patients, administer acyclovir intravenously. 1, 2

Adjunctive Treatments

Managing Pruritus

Prescribe sedating antihistamines (such as diphenhydramine or hydroxyzine) exclusively at nighttime for severe itching—their benefit comes from sedation, not direct anti-pruritic effects. 1, 2

• Non-sedating antihistamines have little to no value in atopic eczema and should not be used. 1, 2
• Daytime use of sedating antihistamines should be avoided; large doses may be required in children. 1

Tar Preparations for Lichenified Lesions

• Consider ichthammol 1% in zinc ointment or coal tar solution 1% for thick, lichenified eczema, as these can be particularly useful for healing chronic lesions. 1, 5

When First-Line Treatment Fails

Indications for Specialist Referral

Refer to a specialist if there is failure to respond to maintenance treatment with mildly potent steroids in children or moderately potent steroids in adults after appropriate duration. 1

• Other referral indications include diagnostic doubt, need for second-line treatment, or when specialist opinion would be valuable. 1

Second-Line Treatments (Specialist-Initiated)

For treatment-resistant cases, specialists may consider topical calcineurin inhibitors (tacrolimus, pimecrolimus), PDE-4 inhibitors, JAK inhibitors, or phototherapy. 5, 2, 4

• Network meta-analysis shows potent topical corticosteroids, tacrolimus 0.1%, and ruxolitinib 1.5% rank among the most effective treatments. 4, 6
• Tacrolimus 0.1% and crisaborole 2% are most likely to cause application-site reactions (burning/warmth), while topical steroids are least likely. 4, 6
• Narrow band ultraviolet B (312 nm) phototherapy has been introduced as an option, though concerns exist about long-term effects including premature skin aging and malignancies, particularly with PUVA. 1

Third-Line: Systemic Treatments (Last Resort)

Systemic corticosteroids have a limited but definite role only for tiding occasional patients through acute severe flares after exhausting all other options—they should never be used for maintenance treatment. 1, 2

• The decision to use systemic steroids should never be taken lightly, with particular concern about pituitary-adrenal suppression and growth interference in children. 1
• For moderate to severe eczema requiring systemic therapy, dupilumab (a biological treatment) is more effective than placebo in achieving EASI75 improvement and POEM score improvement at short-term follow-up (high-certainty evidence). 7
• Other systemic options include cyclosporin, azathioprine, and methotrexate, but these are generally avoided and reserved for selected cases. 8, 7

Safety Considerations for Long-Term Management

Topical Corticosteroid Safety

• Short-term use (median 3 weeks, range 1-16 weeks) of any potency topical steroid does not increase skin thinning risk (low confidence). 4, 6
• However, longer-term use (6-60 months) showed skin thinning in 6/2044 (0.3%) participants treated with mild to potent topical steroids. 4, 6

Topical Calcineurin Inhibitor Safety

• Pimecrolimus (Elidel) should not be used continuously for long periods due to uncertain long-term safety, including a very small number of cancer cases (skin or lymphoma), though a causal link has not been established. 9
• Do not use pimecrolimus on children under 2 years old. 9
• Use only on areas with eczema, for short periods with breaks in between, stopping when symptoms resolve. 9

Unproven or Ineffective Approaches

• Evidence for house dust mite eradication benefits is not strong, and currently there are no effective measures for complete eradication. 1
• Dietary manipulation may be indicated only when patient history strongly suggests specific food allergy or when widespread active eczema is not responding to first-line treatment. 1
• No conclusions can be drawn about evening primrose oil effectiveness—two large trials showed no benefit. 1