What are the prescription treatment options for a patient with moderate to severe eczema, considering their medical history and potential allergies?

Prescription Treatment Options for Moderate to Severe Eczema

For moderate to severe eczema, initiate treatment with potent topical corticosteroids (TCS) applied once daily to affected areas, combined with liberal emollient use to the entire body, and consider proactive (weekend) therapy to prevent relapses once initial control is achieved. 1, 2, 3

First-Line Prescription Approach

Topical Corticosteroids by Severity

Moderate Eczema:

• Use moderate-potency TCS (e.g., mometasone furoate 0.1% ointment) applied once daily to lesional skin 1, 2
• Moderate-potency TCS achieve treatment success in 52% of patients versus 34% with mild-potency agents (OR 2.07) 3
• Once daily application is equally effective as twice daily for potent TCS, reducing unnecessary exposure 3

Severe Eczema:

• Escalate to potent TCS (e.g., betamethasone dipropionate 0.05%) or very potent TCS (e.g., clobetasol propionate 0.05%) applied once daily 1
• Potent TCS achieve 70% treatment success versus 39% with mild-potency agents (OR 3.71) 3
• For widespread severe disease, consider applying very potent TCS to entire body surface (5-15g twice daily) if patient/caregiver capable 1

Essential Concurrent Measures

All patients require:

• Emollients applied liberally (urea- or glycerin-based) to entire body at least once daily, not just affected areas, to restore barrier function 2
• Soap-free cleansers exclusively to prevent further lipid stripping 2, 4
• Evaluate for secondary bacterial infection (Staphylococcus aureus most common) - add flucloxacillin if present, or erythromycin if penicillin-allergic 1, 2, 4

Proactive (Weekend) Therapy to Prevent Relapses

Once initial control achieved:

• Apply moderate-to-potent TCS twice weekly (e.g., weekends) to previously affected areas for up to 36 weeks 1, 2, 3
• This reduces relapse rate from 58% to 25% (RR 0.43) with moderate-certainty evidence 3
• Mometasone furoate achieves 68% remission rate over 36 weeks with this approach 2

Second-Line Prescription Options (When TCS Inadequate)

Topical Calcineurin Inhibitors (TCI)

Indications:

• Moderate eczema refractory to moderate-potency TCS 1, 4
• Facial or intertriginous areas where TCS atrophy risk is higher 1, 4
• Patients requiring long-term maintenance where TCS side effects are concerning 1

Specific agents:

• Tacrolimus 0.1% ointment for adults and children ≥16 years (more effective than pimecrolimus) 1, 5
• Tacrolimus 0.03% ointment for children 2-15 years 1
• Pimecrolimus 1% cream for patients ≥3 months (less effective but better tolerated) 1, 6

Critical safety considerations:

• FDA black box warning regarding malignancy risk is not supported by current evidence - actual lymphoma rates are lower than predicted 4
• Most common adverse effect is application-site burning (occurs in first 5 days, typically resolves) 6, 5
• Do not use in Netherton's syndrome or on malignant/pre-malignant skin conditions 6
• Resolve bacterial/viral infections before initiating TCI 6

Topical PDE-4 Inhibitors

• Crisaborole 2% approved for patients ≥3 months with mild-to-moderate eczema 1
• Less effective than potent TCS or tacrolimus 0.1% but may be useful for maintenance 1, 5
• Application-site reactions occur (OR 2.12 versus vehicle) 5

Topical JAK Inhibitors

• Ruxolitinib 1.5% ranked among most effective treatments (OR 9.34 for IGA success) with moderate confidence 5
• Consider when TCS or TCI inadequate 1

Third-Line Systemic Prescription Options

Phototherapy

Before systemic immunosuppressants:

• Narrowband UVB (NB-UVB) is preferred first-line phototherapy 1
• Effective for moderate-to-severe atopic eczema with strength of recommendation A 1
• Not recommended for children <12 years 1
• Requires 2-3 sessions weekly, typically for several weeks 1

Systemic Immunomodulators (Off-label for pediatrics)

When topical therapy and phototherapy fail:

1. Cyclosporine - first-line systemic choice for acute severe flares 1, 7, 8
2. Methotrexate or Azathioprine - equal secondary choices for chronic management 1, 7
3. Dupilumab (biologic) - approved for patients ≥6 years in Taiwan, consider before traditional immunosuppressants 1, 7

Avoid:

• Oral corticosteroids should be reserved only for severe refractory cases after all other options exhausted 1, 2
• Use only for short courses (<7 days) to "tide over" acute severe exacerbations 1
• Never use for maintenance therapy 1

Adjunctive Prescription Measures

For Severe Pruritus

• Sedating antihistamines (e.g., hydroxyzine) at bedtime only, short-term use 1, 4
• Non-sedating antihistamines have no value in atopic eczema 1
• Therapeutic benefit derives from sedation, not antihistamine effect 1

For Infected Eczema

• Flucloxacillin for Staphylococcus aureus (most common pathogen) 1, 2
• Phenoxymethylpenicillin if β-hemolytic streptococci isolated 1, 2
• Erythromycin for penicillin allergy or flucloxacillin resistance 1, 2
• Oral acyclovir for eczema herpeticum, given early; IV if patient febrile/ill 1

Common Pitfalls to Avoid

Potency selection errors:

• Using mild TCS for moderate-to-severe disease results in treatment failure 1, 3
• Conversely, using very potent TCS when potent TCS would suffice increases unnecessary risk 3

Application frequency misconceptions:

• Applying potent TCS more than once daily provides no additional benefit 3
• Twice daily application does not increase efficacy (OR 0.97,95% CI 0.68-1.38) 3

Short-term TCS safety:

• Skin thinning with short-term TCS use (median 3 weeks) is extremely rare - only 36 events in 3,691 participants across 25 trials 5
• Fear of TCS side effects should not prevent appropriate use for acute control 3, 5

Stopping treatment prematurely:

• Discontinuing TCS once lesions clear leads to rapid relapse 3
• Implement proactive twice-weekly maintenance to previously affected areas 1, 2, 3

When to Refer to Specialist

Indications for dermatology referral: 1, 4

• Diagnostic uncertainty
• Failure to respond to moderate-potency TCS in children or potent TCS in adults
• Need for second-line treatments (TCI, systemic agents, phototherapy)
• Consideration of dietary manipulation or patch testing
• Recurrent secondary infections despite appropriate antibiotics