What is the recommended treatment for a patient with severe, unresponsive eczema, considering age, weight, and past medical history, including prior steroid use?

High-Dose Steroids for Eczema: Not Recommended for Routine Use

Systemic corticosteroids have a limited but definite role only for occasional patients with severe atopic eczema to tide over acute crises, but should never be considered for maintenance treatment and the decision to use them should never be taken lightly. 1

Why Systemic Steroids Are Third-Line Treatment

The British Association of Dermatologists explicitly positions oral corticosteroids as third-line therapy, reserved only after all other treatment avenues have been exhausted 1. This conservative approach stems from several critical concerns:

• Risk of rebound flares: It is particularly important to try to avoid oral corticosteroids during crises, as withdrawal can precipitate severe disease exacerbation 1
• Lack of evidence: Despite frequent use in clinical practice, systemic glucocorticosteroids have not been adequately assessed in studies for eczema 2
• Not recommended for maintenance: They should never be used for ongoing disease control 1

What Should Be Done Instead

First-Line Approach

Before considering any systemic therapy, optimize topical management:

• Topical corticosteroids: Use appropriate potency for body site (moderate potency for most areas, lower potency for face) applied no more than twice daily 1
• Aggressive emollient therapy: Liberal application of fragrance-free emollients, especially after bathing 3
• Soap-free cleansers: Exclusively use these to avoid lipid stripping and barrier disruption 3
• Address infection: Obtain bacterial swabs if treatment failure occurs, as Staphylococcus aureus commonly causes non-response; treat with flucloxacillin or erythromycin if penicillin-allergic 1, 3

For Facial Eczema Specifically

Topical calcineurin inhibitors (tacrolimus 0.1% ointment or pimecrolimus 1% cream) are recommended for moderate facial eczema refractory to moderate-potency topical corticosteroids, while continuing aggressive emollient therapy 3. These avoid steroid-related complications including skin atrophy 3.

When Systemic Treatment Is Truly Needed

If severe eczema remains unresponsive to optimized topical therapy:

Cyclosporine is recommended as the first-option systemic agent for patients with atopic eczema refractory to conventional treatment 2. This recommendation is based on 11 studies consistently showing effectiveness 2. However, cyclosporine requires careful monitoring:

• Renal function monitoring: Frequent serum creatinine checks are mandatory, as 21-30% of psoriasis patients developed nephropathy in studies 4
• Blood pressure monitoring: Hypertension is a known risk 4
• Duration limits: Prolonged use (>15 months) and doses >5 mg/kg/day increase nephrotoxicity risk 4
• Malignancy surveillance: Increased risk for skin and lymphoproliferative malignancies exists 4

Alternative Systemic Options

Evidence from randomized controlled trials also supports:

• Interferon-γ: Has demonstrated efficacy in controlled trials 2
• Azathioprine: Supported by randomized controlled trial evidence 2
• Dupilumab (biological agent): Ranks first for effectiveness among biological treatments, more effective than placebo in achieving EASI75 (RR 3.04,95% CI 2.51 to 3.69) at short-term follow-up with high-certainty evidence 5

Critical Pitfalls to Avoid

Do Not Use High-Potency Steroids on the Face

High-potency topical corticosteroids carry increased risk of skin atrophy on facial skin and should be limited to short courses of 1-2 weeks maximum 3. Systemic absorption and HPA axis suppression risks are elevated with facial application 6.

Avoid Systemic Steroids in Specific Situations

• Eczema herpeticum: Systemic corticosteroids are associated with worse outcomes if vesicles or punched-out erosions suggest viral superinfection; immediate oral acyclovir is required instead 6
• Bacterial superinfection: Address infection first with appropriate antibiotics before escalating immunosuppression 1, 3

Do Not Increase Steroid Potency Blindly

Worsening despite appropriate steroid use may indicate bacterial superinfection, steroid allergy, or contact dermatitis rather than inadequate potency 6. Specialist referral for patch testing is recommended when there is no improvement or worsening after appropriate first-line treatment 3, 6.

When to Refer to Dermatology

Referral is indicated for:

• Failure to respond to maintenance treatment with mildly potent steroids in children or moderately potent steroids in adults 1
• When second-line systemic treatment is being considered 1
• Maximum waiting time should be six weeks for first appointment 1