What is the recommended treatment for a patient with eczema?

Treatment of Eczema (Atopic Dermatitis)

First-Line Treatment: Topical Corticosteroids

Topical corticosteroids are the mainstay of eczema treatment and should be used as first-line therapy, applied once daily (not twice daily) to affected areas using the least potent preparation that controls symptoms. 1, 2

Potency Selection by Body Site

• For hands and feet: Use potent topical corticosteroids (clobetasol propionate 0.05% or mometasone furoate) applied once daily, as these areas have thicker skin that tolerates higher potency steroids better 3

• For face, neck, flexures, and genitals: Start with mild to moderate potency topical corticosteroids (hydrocortisone 1-2.5% or prednicarbate 0.02%) applied once daily, as these thin-skinned areas carry higher risk of atrophy 1, 4

• For trunk and extremities: Use moderate to potent corticosteroids depending on severity 1

Application Strategy

• Apply once daily (not twice daily) - once daily application is equally effective as twice daily for potent topical corticosteroids 2, 5

• Use very potent and potent corticosteroids with caution for limited periods only, implementing short "steroid holidays" when possible 1

• Continue topical corticosteroids even when infection is present, as long as appropriate systemic antibiotics are given concurrently 1

Essential Adjunctive Therapy: Emollients

Liberal use of emollients is the cornerstone of maintenance therapy and must be applied regularly, even when eczema appears controlled. 1

• Apply emollients after bathing to provide a surface lipid film that retards water loss 1

• If using both emollients and topical corticosteroids, apply the topical corticosteroid first, then the emollient afterward 1

• Use soap-free cleansers and avoid alcohol-containing products 1

• Regular bathing for cleansing and hydrating is recommended 1

Proactive (Weekend) Therapy to Prevent Flares

After achieving control with daily topical corticosteroids, switch to twice-weekly application (weekend therapy) to previously affected sites to prevent relapse - this reduces flare risk from 58% to 25%. 2

• Apply topical corticosteroids twice weekly to previously affected areas even when skin appears clear 3, 2

• This "get control then keep control" regimen is more effective than reactive treatment only during flares 5

Managing Pruritus (Itching)

• Sedating antihistamines (diphenhydramine, clemastine) may help with nighttime itching through sedative properties only - prescribe exclusively at bedtime 1, 3, 4

• Non-sedating antihistamines have no value in eczema and should not be used 1, 3, 5

Managing Secondary Bacterial Infection

• Watch for increased crusting, weeping, or pustules indicating Staphylococcus aureus infection 1, 3

• Flucloxacillin is first-line oral antibiotic - continue topical corticosteroids during treatment 1, 3

• Do not delay or withhold topical corticosteroids when infection is present - they remain primary treatment when appropriate systemic antibiotics are given 1

Eczema Herpeticum: Medical Emergency

• Suspect if grouped vesicles, punched-out erosions, or sudden deterioration with fever occur 1, 4

• Initiate oral acyclovir early; use intravenous acyclovir in ill, feverish patients 1, 4

Second-Line Topical Agents

Topical Calcineurin Inhibitors (Pimecrolimus, Tacrolimus)

Use topical calcineurin inhibitors only after topical corticosteroids have failed or for sensitive sites (face, neck, flexures) where corticosteroid side effects are concerning. 6, 5, 7

• Pimecrolimus 1% is less effective than moderate/potent corticosteroids and 0.1% tacrolimus 7

• Do not use in children under 2 years old 6

• Use only for short periods with breaks in between, not continuously long-term 6

• Apply only to areas with active eczema 6

• Most common side effect is application-site burning (more common than with corticosteroids) 8, 7

• Avoid sun exposure during treatment; do not use with phototherapy 6

• Stop if lymphadenopathy develops without clear infectious etiology 6

Newer Agents (JAK Inhibitors, PDE-4 Inhibitors)

• Ruxolitinib 1.5% and delgocitinib 0.5% are highly effective alternatives comparable to potent topical corticosteroids 8

• PDE-4 inhibitors (crisaborole 2%, roflumilast 0.15%) are among the least effective topical anti-inflammatory treatments and should be reserved for cases where other options have failed 8

Systemic Therapy for Severe Disease

Systemic corticosteroids should only be used for acute severe flares requiring rapid control after exhausting all other options, never for maintenance treatment. 1, 3

• Use only for short-term "tiding over" during crisis periods 1

• Risk of pituitary-adrenal suppression and corticosteroid-related mortality with prolonged use 1

Phototherapy

• Narrow band ultraviolet B (312 nm) is an option for moderate-to-severe disease failing topical therapy 1

• For hand and foot eczema, oral PUVA is superior to UVB phototherapy (81-86% achieve significant improvement) 3

• Concern exists about long-term adverse effects including premature skin aging and cutaneous malignancies 1

When to Refer

• Failure to respond to moderate/potent topical corticosteroids after 4 weeks 1, 3, 4

• Need for systemic therapy or phototherapy 1, 3, 4

• Suspected eczema herpeticum (medical emergency) 1

Critical Pitfalls to Avoid

• Do not apply topical corticosteroids twice daily - once daily is equally effective 2, 5

• Do not withhold topical corticosteroids when infection is present - continue with appropriate antibiotics 1

• Do not use very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) 1, 4

• Do not use topical corticosteroids continuously without breaks - implement "steroid holidays" 1

• Do not prescribe non-sedating antihistamines - they have no value in eczema 1, 5

• Do not use topical or oral antistaphylococcal treatments for infected eczema without concurrent topical corticosteroids 5

• Address steroid phobia directly - explain different potencies and benefits/risks clearly, as patient/parent fears often lead to undertreatment 1