What is the first line of treatment for a patient experiencing an eczema flare?

First-Line Treatment for Eczema Flare

Apply liberal amounts of emollients immediately after bathing and use mild-potency topical corticosteroids (1% hydrocortisone) to affected areas 3-4 times daily until the flare resolves. 1, 2

Immediate Management of Active Flare

Emollient Therapy (Foundation of Treatment)

• Apply emollients liberally and frequently to all skin surfaces to maintain hydration and improve barrier function. 1, 2
• Apply immediately after bathing when skin is still damp to lock in moisture and maximize effectiveness. 1, 2
• Replace all regular soaps with soap substitutes (dispersable creams) to prevent removal of natural skin lipids. 1, 2

Topical Corticosteroid Application

• Use 1% hydrocortisone (mild-potency) for facial areas and infants due to increased risk of absorption and side effects. 1, 2, 3
• For body areas in adults and children over 2 years, apply topical corticosteroids to affected areas 3-4 times daily until flare resolves. 3
• Moderate-potency topical corticosteroids increase treatment success from 34% to 52% compared to mild-potency (OR 2.07), and potent topical corticosteroids increase success from 39% to 70% (OR 3.71) for moderate-to-severe eczema. 4
• Once-daily application of potent topical corticosteroids is equally effective as twice-daily application (OR 0.97), so once daily is sufficient for most flares. 4

Potency Selection Algorithm

For mild eczema or facial/infant involvement: Start with mild-potency (1% hydrocortisone). 1, 2

For moderate-to-severe eczema on body areas: Use moderate-potency topical corticosteroids as first-line, escalating to potent if inadequate response after one week. 4

Avoid very potent topical corticosteroids for flares: Evidence does not support superiority over potent preparations (OR 0.53, CI 0.13-2.09), and they carry higher risk of skin thinning. 4

Common Pitfalls to Avoid

• Do not continue ineffective treatment beyond one week—escalate potency or refer if no response. 5
• Do not use topical corticosteroids continuously without breaks—apply only until flare resolves, then transition to maintenance strategy. 6, 1
• Infants have higher body surface area to volume ratio, making them particularly susceptible to systemic absorption and side effects. 1
• The most common adverse event with higher-potency topical corticosteroids is abnormal skin thinning, occurring in approximately 1% of patients, with 16 cases from very potent, 6 from potent, 2 from moderate, and 2 from mild preparations. 4

Adjunctive Treatments During Flare

Managing Pruritus

• Sedating antihistamines may provide short-term relief during severe flares through their sedative properties, not antihistamine effects. 1, 2
• Non-sedating antihistamines have little to no value in eczema and should not be used. 1, 2

Monitoring for Secondary Infection

• Watch for crusting, weeping, or punched-out erosions indicating bacterial superinfection requiring flucloxacillin. 1, 2
• Grouped vesicles or punched-out erosions suggest viral infection (eczema herpeticum) requiring prompt acyclovir treatment. 1, 2

Transition to Maintenance After Flare Resolution

Once the flare resolves, transition to proactive maintenance therapy rather than waiting for the next flare. 6

• Apply topical corticosteroids or topical calcineurin inhibitors twice weekly to previously affected areas even when skin appears clear. 6
• Continue daily emollient use to all areas. 6
• Proactive twice-weekly therapy reduces relapse risk from 58% to 25% (RR 0.43) compared to reactive treatment only. 4
• This approach is based on evidence that clinically normal-appearing skin in eczema patients has persistent subclinical inflammation and barrier defects. 6, 7

When to Refer

Refer to dermatology if: 1, 2

• No response to first-line treatment within 1-2 weeks
• Diagnostic uncertainty exists
• Second-line treatments (topical calcineurin inhibitors, phototherapy, systemic agents) are being considered
• Extensive involvement (>20% body surface area) requiring hospitalization 5