How to manage a patient with whole body eczema?

Management of Whole Body Eczema

Start with aggressive emollient therapy combined with moderate-to-potent topical corticosteroids applied twice daily to all affected areas, as this forms the foundation of treatment for widespread eczema. 1

First-Line Treatment Approach

Topical Corticosteroid Strategy

• Apply moderate-to-potent topical corticosteroids twice daily to all affected body areas, using the least potent preparation that achieves control 1
• For whole body involvement, you'll need to stratify potency by body region: use potent steroids (like clobetasol 0.05% or mometasone) on trunk and extremities where skin is thicker, but step down to moderate potency on thin-skinned areas (face, neck, flexures, genitals) to avoid atrophy 1, 2
• Implement "steroid holidays" (short breaks) when possible to minimize systemic absorption risk and local side effects, which is particularly important given the large body surface area being treated 1
• Very potent corticosteroids should be used with caution and for limited periods only 3, 1

Critical pitfall: With whole body application, the risk of pituitary-adrenal suppression increases substantially due to the large surface area absorbing corticosteroids 3. Monitor for signs of systemic absorption, especially in children.

Essential Emollient Therapy

• Apply emollients liberally at least 3-4 times daily to the entire body, immediately after bathing (within 3 minutes of patting skin dry) to trap moisture 4, 1
• Expect to use 200-400 grams per week for whole body application in adults 4
• Use thick ointments or creams rather than lotions for maximum occlusion and penetration, selecting fragrance-free formulations to avoid irritation 4
• Continue aggressive emollient use even when lesions appear controlled - this is the cornerstone of maintenance therapy and has documented steroid-sparing effects 4, 1

Bathing Protocol

• Bathe daily using lukewarm water only, limiting duration to 10-15 minutes 4
• Use soap-free cleansers exclusively and avoid alcohol-containing products, as soaps remove natural skin lipids and worsen the condition 4, 1

Managing Complications

Secondary Bacterial Infection

• Watch for increased crusting, weeping, or pustules - these indicate secondary Staphylococcus aureus infection, which is common in widespread eczema 4, 1
• Add oral flucloxacillin as first-line antibiotic while continuing topical corticosteroids 4, 1
• Do not delay or withhold topical corticosteroids when infection is present - they remain the primary treatment when appropriate systemic antibiotics are given concurrently 1

Eczema Herpeticum (Medical Emergency)

• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum 1
• Initiate oral acyclovir early; if the patient is ill or febrile, administer acyclovir intravenously 1

Pruritus Management

• Prescribe sedating antihistamines (diphenhydramine or hydroxyzine) exclusively at nighttime for severe itching, as their benefit comes from sedation rather than direct anti-pruritic effects 3, 4, 1
• Large doses may be required in children 3
• Non-sedating antihistamines have no value in eczema and should not be used 1, 2

Second-Line Treatment for Refractory Cases

Phototherapy

• Consider narrow band ultraviolet B (312 nm) phototherapy for whole body eczema failing first-line topical therapy 3, 1
• Some concern exists about long-term adverse effects such as premature skin aging and cutaneous malignancies, particularly with PUVA, though narrow band UVB has a better safety profile 3, 1

Proactive Maintenance After Clearance

• After achieving clearance, apply topical corticosteroids twice weekly (weekend therapy) to previously affected sites to prevent relapse 4

Third-Line Treatment (Use with Extreme Caution)

Systemic Corticosteroids

• Systemic corticosteroids have a limited but definite role only for tiding occasional patients through acute severe flares after exhausting all other options 3, 1
• The decision to use systemic steroids should never be taken lightly, and they should not be considered for maintenance treatment 3
• It is particularly important to try to avoid oral corticosteroids during crises - this seems counterintuitive, but the guideline emphasizes exhausting topical options first 3

Major concern: With whole body eczema, patients may have substantial lifetime corticosteroid exposure, increasing risk of corticosteroid-related side effects and mortality 5. Careful prescribing practices and monitoring are essential.

When to Refer to Specialist

Refer immediately if: 3, 1

• Failure to respond to moderate-to-potent topical corticosteroids after 4 weeks
• Need for systemic therapy or phototherapy
• Suspected eczema herpeticum (medical emergency)
• Diagnostic doubt

A period as an inpatient may help overcome severe flares when outpatient management fails 3. Specialists should start with first-line treatment measures again, reinforcing compliance aspects before escalating to second-line treatments 3.

Adjunctive Considerations

Allergen Avoidance

• A trial of dietary manipulation may be indicated when widespread active eczema is not responding to first-line treatment or when patient history strongly suggests specific food allergy 3
• Evidence for house dust mite eradication benefits is not strong, and currently there are no effective measures for complete eradication 3

Psychological Support

• Patients may benefit from cognitive behavioral techniques such as relaxation therapy or self-hypnosis 3
• Access to a clinical psychologist is recommended, as experiences with other patients can help reduce feelings of helplessness and isolation 3