What is the best approach to manage atopic eczema in a patient?

Management of Atopic Eczema

Topical corticosteroids are the mainstay of treatment for atopic eczema and should be initiated as first-line therapy, using the least potent preparation that controls symptoms, applied no more than twice daily to affected areas. 1, 2

First-Line Treatment Strategy

Topical Corticosteroids

• Start with mild-potency corticosteroids for mild eczema in children, or moderate-potency for adults 1, 3
• Apply twice daily maximum—more frequent application does not improve efficacy but increases side effects 2, 3
• Use potent or very potent corticosteroids only for limited periods and with caution 1
• Implement "steroid holidays" (short breaks) when possible to minimize adverse effects 2
• The hands and feet tolerate higher potency steroids better than thin-skinned areas (face, neck, flexures, genitals) due to thicker stratum corneum 4
• A critical pitfall: patients' or parents' fears of steroids often lead to undertreatment—clearly explain the different potencies and the benefits/risks 1, 2

Recent network meta-analysis evidence (2024) confirms that potent TCS rank among the most effective treatments, with potent TCS showing OR 5.99 (95% CI 2.83-12.69) for patient-reported symptom improvement and OR 8.15 (95% CI 4.99-13.57) for clinician-reported signs 5

Essential Emollient Therapy

• Liberal use of emollients is the cornerstone of maintenance therapy—apply regularly even when eczema appears controlled 2, 3
• Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss 1, 2
• Continue aggressive emollient use throughout treatment 4

Avoidance of Provoking Factors

• Use soap-free cleansers exclusively—soaps and detergents remove natural lipids and worsen dry skin 1, 2, 3
• Avoid extremes of temperature 1
• Keep nails short to minimize scratching damage 1, 3
• Avoid irritant clothing such as wool next to skin; cotton clothing is preferred 1

Bathing Regimen

• Regular bathing is useful for cleansing and hydrating the skin 1
• Allow patients to decide on the most suitable bath oil and bathing regimen 1

Managing Pruritus

Use sedating antihistamines exclusively at nighttime for severe pruritus—their benefit comes from sedation, not direct anti-pruritic effects. 1, 2, 3, 4

• Large doses may be required in children 1
• Daytime use should be avoided due to sedation 1
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used 1, 2, 3
• The value of antihistamines may be progressively reduced due to tachyphylaxis 1

Managing Secondary Infections

Bacterial Infections

• Watch for signs of secondary bacterial infection: increased crusting, weeping, or pustules 1, 2, 4
• Flucloxacillin is first-line oral antibiotic for Staphylococcus aureus, the most common pathogen 1, 2, 4
• Phenoxymethylpenicillin for β-hemolytic streptococci 1
• Erythromycin for flucloxacillin resistance or penicillin allergy 1
• Critical: Do not delay or withhold topical corticosteroids when infection is present—continue them alongside appropriate systemic antibiotics 2, 4

Eczema Herpeticum (Medical Emergency)

• Suspect eczema herpeticum if you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever 1, 2
• Initiate oral acyclovir early in the disease course 1, 2
• In ill, feverish patients, administer acyclovir intravenously 1, 2

Second-Line Treatments

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% and pimecrolimus 1% can be used in conjunction with topical corticosteroids 6
• Network meta-analysis shows tacrolimus 0.1% ranks among the most effective treatments (OR 6.27,95% CI 1.19-32.98 for patient symptoms; OR 5.06,95% CI 3.59-7.13 for IGA) 5
• Most likely to cause application-site reactions (burning sensation) compared to TCS, typically only during first days of treatment 7, 5
• Consider for maintenance therapy or as corticosteroid alternative 3

Tar Preparations

• Ichthammol is less irritant than coal tar and may be applied as 1% ointment in zinc ointment or paste bandages, particularly useful for lichenified eczema 1
• Coal tar solution (1% strength) is generally preferred to crude coal tar 1

Phototherapy

• Narrow band ultraviolet B (312 nm) is an option for moderate to severe atopic eczema when first-line treatments fail 1, 2, 6
• For hand and foot eczema, oral PUVA is superior to UVB, with 81-86% achieving significant improvement 4
• Some concern exists about long-term adverse effects such as premature skin aging and cutaneous malignancies, particularly with PUVA 1, 2

Third-Line Treatment: Systemic Corticosteroids

Systemic corticosteroids have a limited but definite role only for tiding occasional patients with severe atopic eczema through acute crises—they should never be used for maintenance treatment. 1, 2, 3

• The decision should never be taken lightly 1
• Should not be considered until all other avenues have been explored 1, 3
• Try to avoid oral corticosteroids during crises when possible 1, 3
• Risk of pituitary-adrenal suppression, particularly with prolonged use 1, 2

Proactive Maintenance Therapy

After achieving clearance with acute treatment:

• Consider proactive maintenance therapy with topical corticosteroids applied twice weekly to previously affected sites to prevent relapse 4, 8
• Continue ongoing emollient treatment of unaffected skin 8

When to Refer to a Specialist

Refer when: 1, 2, 4

• Diagnostic doubt exists
• Failure to respond to moderate-potency topical corticosteroids in adults or mild-potency in children after 4 weeks
• Second-line treatment required (phototherapy, systemic therapy)
• Dietary manipulation being considered
• Suspected eczema herpeticum (medical emergency)

Maximum waiting time for first appointment should be six weeks 1

Additional Considerations

Dietary Manipulation

• A trial of dietary manipulation may be indicated when patient's history strongly suggests specific food allergy or when widespread active eczema is not responding to first-line treatment 1
• Access to a dietitian is recommended 1

Psychological Support

• Patients may benefit from cognitive behavioral techniques such as relaxation therapy or self-hypnosis 1
• Access to a clinical psychologist is recommended 1
• Support groups can help reduce feelings of helplessness and isolation 1

Newer Agents

Recent network meta-analysis (2024) shows JAK inhibitors (ruxolitinib 1.5%, delgocitinib 0.5%) rank among the most effective treatments, while PDE-4 inhibitors (roflumilast 0.15%, crisaborole 2%) rank among the least effective 5