What is the recommended skin care routine for a patient with eczema?

Recommended Skin Care Routine for Eczema

The cornerstone of eczema management is liberal and frequent application of emollients combined with appropriate use of topical corticosteroids, while avoiding soaps and maintaining proper bathing practices. 1, 2

Essential Daily Skin Care Practices

Cleansing and Bathing

• Use dispersible creams or mild, pH-neutral (pH 5) non-soap cleansers as soap substitutes to preserve the skin's natural lipid barrier, as soaps and detergents strip natural oils from already dry skin 1, 3, 2
• Bathe with tepid (not hot) water for cleansing and hydrating the skin 1, 3
• Recent evidence shows no difference in eczema symptoms between daily versus weekly bathing, giving patients flexibility to choose what works best for them 4
• Pat skin dry with clean, smooth towels rather than rubbing 3

Emollient Application (Most Critical Step)

• Apply emollients immediately after bathing to damp skin to provide a surface lipid film that retards evaporative water loss from the epidermis 1, 2
• Use emollients liberally and frequently throughout the day—patients with mild eczema typically apply 1.8 times daily, while those with moderate-to-severe disease apply 2.8 times daily 5
• Reapply moisturizer every 3-4 hours and after each face washing 3
• Choose fragrance-free, non-herbal formulations containing petrolatum or mineral oil, as most patients prefer non-fragrant white creams 3, 5
• Continue regular emollient use even when eczema appears controlled, as this is the cornerstone of maintenance therapy 2

Products and Irritants to Avoid

• Avoid all alcohol-containing preparations, especially on the face, as they significantly worsen dryness and trigger flares 3, 2
• Avoid perfumes, deodorants, and harsh soaps 3
• Avoid products containing common allergens including neomycin, bacitracin, and fragrances 3
• Do not wear wool or other irritant fabrics next to the skin; cotton clothing is preferred 1
• Avoid extremes of temperature 1

Topical Corticosteroid Use

Topical corticosteroids are the mainstay of treatment for active eczema and should be used without hesitation when needed. 1, 2

Application Guidelines

• Use the least potent preparation required to control the eczema 1, 2
• Apply no more than twice daily to affected areas (once daily is as effective as twice daily for most patients) 2, 6
• Hydrocortisone 1% is appropriate for mild inflammation and can be used for temporary relief of itching 7
• Very potent and potent corticosteroids should be used with caution for limited periods only (2-4 weeks maximum, especially on the face), with short "steroid holidays" when possible 2, 8
• Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is higher 2

Critical Point About Steroid Fears

Undertreatment due to fear of steroid side effects is a common pitfall—patients and parents need clear education about different potencies and the benefits versus risks, as lack of adherence often traces back to steroid fears 1, 2

Managing Pruritus and Preventing Scratching

• Keep nails short to minimize trauma from scratching 1, 3, 8
• Sedating antihistamines (not non-sedating ones) may help with nighttime itching through their sedative properties during severe flares, but should only be used short-term 1, 2
• Non-sedating antihistamines have little to no value in eczema and should not be used 3, 2, 6

Monitoring for Complications

Secondary Bacterial Infection

Watch for signs including increased crusting, weeping, or pustules, which indicate Staphylococcus aureus infection requiring oral flucloxacillin 1, 3, 2

Eczema Herpeticum (Medical Emergency)

If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum and initiate oral acyclovir immediately 1, 3, 2

When to Escalate Treatment

Refer to dermatology if: 3, 2

• Diagnostic uncertainty or atypical presentation
• Failure to respond to moderate potency topical corticosteroids after 4 weeks
• Recurrent severe flares despite optimal maintenance therapy
• Need for systemic therapy or phototherapy

Common Pitfalls to Avoid

• Do not delay topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given concurrently 2
• Do not use topical corticosteroids continuously without breaks 2, 8
• Avoid greasy or occlusive products that can promote folliculitis 3
• Do not use emollient bath additives, as large trials show no benefit 6
• Avoid oral or topical antistaphylococcal treatments for routine infected eczema without systemic signs, as evidence does not support their use 6