What treatment can I provide in a primary care setting for a patient presenting with eczema, considering their potential history of allergies or asthma?

Primary Care Treatment for Eczema

The cornerstone of eczema management in primary care is liberal use of emollients combined with appropriately potent topical corticosteroids for flare-ups, with consideration of proactive maintenance therapy to prevent relapses. 1, 2

First-Line Treatment Approach

Emollient Therapy (Foundation of All Treatment)

• Prescribe emollients in adequate quantities and instruct patients to apply liberally and frequently to maintain skin hydration and improve barrier function 1, 2
• Apply emollients immediately after bathing while skin is still damp to lock in moisture 2
• Replace regular soaps with soap substitutes (dispersible creams) to prevent removal of natural skin lipids 1, 2
• Continue daily emollient use even when skin appears clear 2

Topical Corticosteroid Selection for Flare-Ups

Choose corticosteroid potency based on age, body site, and disease severity: 1

• Infants and facial/flexural areas: Start with mild potency (1% hydrocortisone) 2
• Children with moderate disease: Moderate-potency corticosteroids are significantly more effective than mild (52% vs 34% treatment success, OR 2.07) 3
• Moderate to severe disease in children/adults: Potent corticosteroids show large benefit over mild potency (70% vs 39% treatment success, OR 3.71) 3
• Very potent corticosteroids: Reserve for specialist use; evidence for superiority over potent preparations is uncertain 3

Application frequency: Once-daily application of potent topical corticosteroids is equally effective as twice-daily use (OR 0.97), so prescribe once daily to minimize exposure 3, 4

Duration and Transition Strategy

• Apply topical corticosteroids only until the flare resolves (typically days to weeks), then stop 2, 5
• After flare resolution, transition to proactive maintenance therapy rather than waiting for the next flare 2

Proactive Maintenance Therapy (Preventing Relapses)

Apply topical corticosteroids twice weekly to previously affected areas even when skin appears clear, continuing daily emollients everywhere 2

This approach dramatically reduces relapse risk:

• Relapse rate drops from 58% to 25% (RR 0.43) with weekend proactive therapy 3
• Patients have 3.5-fold lower risk of relapse compared to emollient alone 6
• Probability of remaining relapse-free at 16 weeks: 87% vs 66% with emollient alone 6

Managing Treatment Complications

Secondary Bacterial Infection

Look for crusting, weeping, or failure to respond to standard treatment 1

• Send bacterial swabs if suspected 1
• Flucloxacillin is the most appropriate antibiotic for Staphylococcus aureus, the most common pathogen 1

Viral Infections

Watch for grouped punched-out erosions or vesiculation suggesting herpes simplex (eczema herpeticum) 1

• Send swabs for virological screening and electron microscopy if suspected 1
• Treat promptly with acyclovir; use intravenous route in ill, febrile patients 1

Contact Dermatitis

Consider allergic contact dermatitis if previously stable eczema suddenly deteriorates, especially with facial/eyelid predominance 1, 7

• Common allergens include nickel, neomycin, fragrance, formaldehyde, lanolin 7

Second-Line Options (When First-Line Fails)

Topical Calcineurin Inhibitors

Pimecrolimus 1% cream is FDA-approved for patients ≥2 years old but should be reserved for when topical corticosteroids are inappropriate 5

Key limitations and warnings: 5

• Less effective than moderate/potent corticosteroids and 0.1% tacrolimus 8
• Black box warning: Long-term safety unknown; possible cancer risk (though causal link not established)
• Use only on eczematous areas, not continuously long-term 5
• Most common side effect is transient burning (usually resolves in 3-4 days) 5
• Avoid sun exposure during treatment 5

Tacrolimus 0.03% ointment (applied once or twice daily) is more efficacious than 1% hydrocortisone in moderate-severe pediatric eczema, with twice-daily application showing greatest benefit in severe disease 9

Antihistamines

Sedating antihistamines may provide short-term benefit during severe flares primarily through sedative effects to reduce nighttime scratching 1, 2

• Non-sedating antihistamines have little to no value in atopic eczema 2
• Large doses may be required in children; use only at bedtime 1

Interventions NOT Recommended in Primary Care

• House dust mite eradication: Not currently recommended due to lack of strong evidence 1
• Dietary restriction: Little to no benefit in adults; in children, only consider in selected infants under professional supervision with strong history suggesting food allergy 1
• Evening primrose oil: Evidence remains inconclusive 1

When to Refer to Specialist

Refer to dermatology when: 1, 2, 7

• Failure to respond to first-line treatment (mild-potency steroids in children, moderate-potency in adults)
• Diagnostic uncertainty
• Severe disease requiring systemic therapy
• Consideration of second-line treatments (phototherapy, immunosuppressants)
• Strong suspicion of allergic contact dermatitis requiring patch testing 7
• Suspected food allergy with documented correlation in food diary 7

Critical Pitfalls to Avoid

• Inadequate patient education: Time spent explaining application technique and quantities is essential; demonstrate application and provide written instructions 1
• Underprescribing emollients: These should be prescribed in large quantities for liberal use 1
• Continuous corticosteroid use without breaks: Apply only until flare resolves, then transition to maintenance strategy 2
• Using very potent corticosteroids in primary care: These carry higher risk of adverse effects and should be reserved for specialists 3
• Ignoring secondary infection: Deterioration in stable eczema often indicates bacterial or viral superinfection 1