What is the recommended treatment for a patient experiencing an eczema flare-up?

Treatment of Eczema Flare-Up

For an acute eczema flare-up, apply potent topical corticosteroids (such as clobetasol propionate 0.05% or mometasone furoate) twice daily to affected areas until the flare resolves, then transition immediately to proactive maintenance therapy with twice-weekly application to previously affected sites to prevent relapse. 1, 2

First-Line Treatment During Active Flare

Topical Corticosteroid Selection and Application

• Apply potent topical corticosteroids twice daily to all affected areas until signs and symptoms (itching, rash, redness) resolve 1, 2
• Potent corticosteroids are significantly more effective than mild corticosteroids for moderate to severe eczema, with 70% versus 39% achieving treatment success 3
• Once-daily application of potent corticosteroids is equally effective as twice-daily application, so once daily may be used if adherence is challenging 3
• Hands and feet tolerate higher potency steroids better than facial or flexural areas due to thicker stratum corneum 1
• For facial eczema, use mild-potency corticosteroids (1% hydrocortisone) or prednicarbate 0.02% cream for more significant inflammation 2, 4

Essential Concurrent Emollient Therapy

• Apply emollients liberally and frequently throughout the day, immediately after hand washing and bathing, to provide a surface lipid film that retards water loss 1, 2
• If using both emollients and topical corticosteroids, apply the corticosteroid first, then the emollient after 2
• Use soap-free cleansers exclusively and avoid hot water, as these remove natural skin lipids and aggravate eczema 1, 4

Managing Pruritus

• Prescribe sedating antihistamines (such as diphenhydramine) exclusively at nighttime to help patients sleep through severe itching episodes 1, 2
• The therapeutic value comes from sedation, not direct anti-pruritic effects 2
• Non-sedating antihistamines have no value in eczema and should not be used 1, 2

Identifying and Treating Secondary Infection

• Watch for increased crusting, weeping, or punched-out erosions, which indicate secondary bacterial infection with Staphylococcus aureus 1, 2
• Add oral flucloxacillin as first-line antibiotic while continuing topical corticosteroids 1, 2
• Do not delay or withhold corticosteroids when infection is present 1
• Grouped, punched-out erosions suggest herpes simplex (eczema herpeticum) requiring prompt treatment with acyclovir 2

Transition to Proactive Maintenance Therapy

Critical Strategy to Prevent Relapse

• After flare resolution, immediately transition to proactive maintenance therapy rather than waiting for the next flare 2, 5
• This approach reduces relapse risk from 58% to 25% (RR 0.43) compared to reactive treatment only 2, 3
• The rationale is that clinically normal-appearing skin in eczema patients has persistent subclinical inflammation and barrier defects 2, 6

Proactive Maintenance Protocol

• Apply topical corticosteroids or topical calcineurin inhibitors twice weekly to previously affected areas even when skin appears clear 2, 3
• Continue daily emollient use to all areas 2
• Do not use topical corticosteroids continuously without breaks 2

Second-Line Options for Refractory Cases

Topical Calcineurin Inhibitors

• Consider pimecrolimus 1% cream or tacrolimus 0.1% ointment for patients who fail topical corticosteroids after 4 weeks 1, 5
• Tacrolimus 0.1% is ranked among the most effective topical anti-inflammatory treatments, with similar effectiveness to potent corticosteroids 5
• Pimecrolimus is less effective than moderate and potent corticosteroids and 0.1% tacrolimus 7
• Apply twice daily only to areas with eczema for short periods, with treatment repeated with breaks in between 8
• Stop when signs and symptoms resolve 8
• The most common side effect is application-site burning or warmth, usually mild to moderate, occurring during the first 5 days and clearing within a few days 8, 5
• Avoid sun lamps, tanning beds, or ultraviolet light therapy during treatment 8
• Not approved for children under 2 years old 8

Phototherapy

• For eczema failing topical therapy, narrowband UVB phototherapy is effective, with good evidence supporting its use in chronic atopic eczema 9
• Twice-weekly narrowband UVB was superior to low-dose broadband UVA or visible light placebo in adults with moderate to severe atopic eczema 9

Safety Considerations for Topical Corticosteroids

Short-Term Use (Median 3 Weeks)

• No evidence for increased skin thinning with short-term use of mild, moderate, potent, or very potent topical corticosteroids 3
• In trials testing flare-up strategies, only 26 cases of abnormal skin thinning occurred from 2266 participants (1%) across 22 trials 3
• Most cases were from higher-potency corticosteroids (16 with very potent, 6 with potent) 3

Longer-Term Use (6-60 Months)

• Increased skin thinning occurs with longer-term mild to potent topical corticosteroids versus topical calcineurin inhibitors 3
• Systemic corticosteroids should only be used for acute severe flares requiring rapid control after exhausting all other options, never for maintenance treatment 1

When to Refer to Dermatology

• Failure to respond to potent topical corticosteroids after 4 weeks warrants referral 1, 2
• Diagnostic uncertainty or atypical presentation 2
• Need for phototherapy or systemic immunosuppressive therapy 1
• Recurrent severe flares despite optimal maintenance therapy 4

Common Pitfalls to Avoid

• Undertreatment due to fear of steroid side effects is a major pitfall—use appropriate potency for adequate duration 4, 3
• Applying moisturizers immediately before phototherapy creates a bolus effect and should be avoided 4
• Greasy or occlusive products can facilitate folliculitis development 4
• Rubbing skin dry after bathing (should pat dry instead) can exacerbate eczema 4