What is the best treatment approach for a patient with severe eczema, possibly with a history of staphylococcal infections?

Treatment of Severe Eczema

For severe eczema, initiate treatment with high-potency topical corticosteroids applied twice daily combined with aggressive emollient therapy, and if the patient has a history of recurrent staphylococcal infections, add dilute bleach baths (0.005% sodium hypochlorite) twice weekly. 1, 2

First-Line Topical Therapy

• Apply high-potency or ultra-high potency topical corticosteroids (such as clobetasol propionate) to affected areas twice daily for up to 2 consecutive weeks maximum, as super-high potency steroids should not exceed 50g per week or 2 weeks of continuous use. 2, 3

• Combine topical corticosteroids with liberal and frequent emollient application—this is mandatory even after lesions appear controlled, as emollients restore the epidermal barrier and should be applied immediately after bathing. 1, 2, 4

• Use soap-free cleansers and avoid hot water, as these strip natural skin lipids and worsen the condition. 2, 4

Managing Infection-Prone Patients

• For patients with recurrent staphylococcal infections, add dilute bleach baths (0.005% sodium hypochlorite) twice weekly in conjunction with topical anti-inflammatory therapy—this is the only antimicrobial intervention with guideline support. 1

• Watch for overt secondary bacterial infection (increased crusting, weeping, pustules) and treat with oral flucloxacillin as first-line antibiotic for Staphylococcus aureus. 1, 2

• Do not use systemic or topical antibiotics in clinically uninfected eczema—evidence shows no clinical benefit despite reducing bacterial counts. 5, 6

• If grouped vesicles, punched-out erosions, or sudden deterioration with fever occur, suspect eczema herpeticum and initiate oral or intravenous acyclovir immediately—this is a medical emergency. 1, 7

Adjunctive Measures for Severe Pruritus

• Prescribe sedating antihistamines (diphenhydramine, clemastine) exclusively at nighttime to help patients sleep through severe itching—their benefit is purely sedative, not anti-pruritic. 1, 2, 5

• Non-sedating antihistamines should not be used as they provide no benefit in eczema without concurrent urticaria or rhinoconjunctivitis. 1, 5, 4

Proactive Maintenance After Achieving Control

• Once clearance is achieved, implement proactive (weekend) therapy with topical corticosteroids applied twice weekly to previously affected sites to prevent relapse. 2, 8

• Continue daily aggressive emollient use even when skin appears clear. 2, 8

Second-Line Therapy for Refractory Disease

• For severe eczema refractory to topical treatments, phototherapy (narrowband UVB) is the next step—it has strong evidence for efficacy in chronic atopic eczema. 1

• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) are effective steroid-sparing agents that can be used in conjunction with topical corticosteroids, particularly for sensitive areas like the face. 1, 4, 8

Systemic Therapy: Critical Considerations

• If systemic therapy is required, cyclosporine is significantly more efficacious than prednisolone for severe adult eczema and should be the first systemic agent considered (2.7-4.0 mg/kg daily for 6 weeks). 1, 9

• Systemic corticosteroids should generally be avoided—they lead to rebound flares after discontinuation and do not induce stable remission. 1, 9

• If systemic corticosteroids are used, limit them to short courses only as bridge therapy to other systemic treatments in acute severe exacerbations. 1

• Other systemic immunosuppressants (azathioprine, methotrexate) should be considered before mycophenolate mofetil or interferon-gamma. 1

Common Pitfalls to Avoid

• Do not withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given concurrently. 2

• Avoid "steroid phobia" leading to undertreatment—guidelines emphasize that topical corticosteroids are safe and effective when used appropriately with intermittent breaks. 1, 2

• Do not use topical corticosteroids more than twice daily—once daily application is equally effective. 5

• Avoid very potent corticosteroids on thin-skinned areas (face, groin, axillae, retroauricular) due to increased risk of atrophy and HPA axis suppression. 1, 7, 3

When to Refer to Specialist

• Refer if there is failure to respond to high-potency topical corticosteroids after 4 weeks of appropriate treatment. 7, 2

• Refer when systemic therapy or phototherapy is being considered. 7