What is the recommended treatment for a patient with eczema?

Treatment of Eczema (Atopic Dermatitis)

First-Line Treatment: Topical Corticosteroids

Use topical corticosteroids as the mainstay of treatment, applying the least potent preparation that controls symptoms, no more than twice daily to affected areas. 1

Selecting Corticosteroid Potency

• Start with mild potency corticosteroids (1% hydrocortisone) for mild eczema, moderate potency for moderate disease, and potent corticosteroids for severe eczema. 2, 1
• Potent and moderate topical corticosteroids are significantly more effective than mild preparations, particularly in moderate or severe eczema (70% vs 39% treatment success for potent vs mild; 52% vs 34% for moderate vs mild). 3, 4
• Very potent and potent corticosteroids should be used with caution for limited periods only, with short "steroid holidays" when possible. 2, 1
• Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where risk of atrophy is higher. 1, 5

Application Frequency and Duration

• Apply topical corticosteroids once daily—this is equally effective as twice daily application for potent preparations. 1, 4
• Once daily application of potent topical corticosteroids does not decrease treatment success compared to twice daily use (OR 0.97,95% CI 0.68 to 1.38). 4
• Stop topical corticosteroids when signs and symptoms (itching, rash, redness) resolve, or as directed. 1
• Implement short breaks ("steroid holidays") when eczema is controlled to minimize side effects, particularly pituitary-adrenal suppression in children. 2, 1

Essential Adjunctive Therapy: Emollients

Apply emollients liberally and regularly, even when eczema appears controlled—this is the cornerstone of maintenance therapy. 1, 6

• Apply emollients after bathing to provide a surface lipid film that retards water loss. 1, 5
• Use soap-free cleansers and avoid alcohol-containing products. 1, 5
• Regular bathing for cleansing and hydrating the skin is recommended. 1
• If using moisturizers with topical corticosteroids, apply emollients after the corticosteroid. 1, 6

Managing Pruritus

Use sedating antihistamines at nighttime only for severe itching—their benefit comes from sedation, not direct anti-pruritic effects. 2, 1, 5

• Non-sedating antihistamines have little to no value in atopic eczema and should not be used. 2, 1, 5
• Antihistamines are short-term adjuvants during severe flares associated with severe pruritus, not maintenance therapy. 2, 1
• Large doses may be required in children, and daytime use should be avoided. 2

Managing Secondary Bacterial Infections

Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not withhold steroids. 1, 5, 6

• Watch for signs of secondary bacterial infection: increased crusting, weeping, or pustules. 1, 5
• Flucloxacillin is first-line oral antibiotic for Staphylococcus aureus, the most common pathogen. 2, 1, 5, 6
• Use phenoxymethylpenicillin if β-hemolytic streptococci are isolated. 2, 5
• Erythromycin may be used when there is resistance to flucloxacillin or in patients with penicillin allergy. 2

Recognizing 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, 5, 6

• Eczema herpeticum responds to oral acyclovir, and the drug should be given early in the course of the disease. 2, 1
• In ill, feverish patients, administer acyclovir intravenously. 2, 1, 5

Proactive (Weekend) Therapy to Prevent Flares

Apply topical corticosteroids twice weekly (weekend therapy) to previously affected areas to prevent relapse—this reduces flare-ups from 58% to 25%. 1, 4

• Weekend (proactive) therapy with topical corticosteroids is significantly better than no topical corticosteroids/reactive use only (RR 0.43,95% CI 0.32 to 0.57). 4
• This strategy is appropriate after initial control is achieved with daily treatment. 1

Alternative Topical Agents

Topical Calcineurin Inhibitors (Pimecrolimus, Tacrolimus)

• Topical calcineurin inhibitors are approved only for children 2 years and older and adults—do NOT use in children under 2 years. 6, 7
• Use only after other prescription medicines have not worked or if your doctor recommends that other prescription medicines should not be used. 7
• Do not use continuously for long periods—use for short periods with breaks in between. 7
• Tacrolimus 0.1% and pimecrolimus 1% are most likely to cause application-site reactions (burning, warmth) compared to topical corticosteroids. 3
• The safety of long-term use is not known; a very small number of people have had cancer (skin or lymphoma), though a causal link has not been established. 7
• Avoid sun exposure, tanning beds, and ultraviolet light therapy during treatment. 7

Coal Tar and Ichthammol

• Ichthammol (1% in zinc ointment) is less irritant than coal tar and may be useful for healing lichenified eczema. 2, 5
• Coal tar solution (1% in hydrocortisone ointment) is generally preferred to crude coal tar. 2, 5

Systemic Therapy for Severe Disease

Systemic corticosteroids have a limited but definite role only for tiding occasional patients with severe atopic eczema through acute crises after all other treatment avenues have been explored. 2, 1

• Oral steroids should not be used for maintenance treatment or to induce stable remission. 1
• The decision to use systemic steroids should never be taken lightly due to risk of pituitary-adrenal suppression and other adverse effects. 2, 1
• Narrow band ultraviolet B (312 nm) phototherapy has been introduced as an option, though concerns exist about long-term adverse effects such as premature skin aging and cutaneous malignancies, particularly with PUVA. 2, 1

Critical Safety Considerations

Skin Thinning Risk

• Abnormal skin thinning occurred in only 1% of participants across short-term trials (median 3 weeks), with most cases from higher-potency preparations (very potent > potent > moderate > mild). 3, 4
• Short-term use (1-16 weeks) of mild to very potent topical corticosteroids showed no evidence for increased skin thinning. 3
• Longer-term use (6-60 months) showed increased skin thinning with mild to potent topical corticosteroids versus topical calcineurin inhibitors. 3

Addressing Steroid Phobia

• Patients' or parents' fears of steroids often lead to undertreatment—explain the different potencies and that appropriate use has favorable safety profiles. 2, 1, 6
• The main risk with topical corticosteroids is suppression of the pituitary-adrenal axis with possible interference of growth in children, primarily with prolonged use of potent/very potent preparations. 2

When to Refer to Specialist

Refer patients who fail to respond to moderate potency topical corticosteroids after 4 weeks, need for systemic therapy or phototherapy, or suspected eczema herpeticum (immediate referral). 1, 5, 6

• Most people with eczema will respond well to first-line management and do not require referral to a specialist. 2