What is the best treatment for a pregnant patient experiencing an eczema flare?

Treatment of Eczema Flare in Pregnancy

For a pregnant patient with an eczema flare, start with daily emollients after bathing combined with moderate-potency topical corticosteroids on affected areas, avoiding very potent formulations. 1, 2

First-Line Management Strategy

Foundation Therapy (All Patients)

• Apply emollients regularly, especially immediately after bathing, as the cornerstone of treatment to maintain skin barrier function and reduce inflammation 1, 2, 3
• Use emollients liberally and frequently throughout the day, not just with bathing 3
• Wear loose, breathable clothing made from natural fabrics to minimize friction and irritation 1, 2

Topical Corticosteroids

• Use moderate-potency topical corticosteroids as first-line pharmacologic treatment for active eczema lesions 2, 3
• Avoid very potent or high-potency topical corticosteroids, particularly in the first trimester 1, 2
• The evidence shows no causal association between mild-to-moderate potency topical corticosteroids and adverse pregnancy outcomes including congenital abnormalities, preterm delivery, or low birth weight 4, 5

Alternative Topical Agent

• Topical tacrolimus can be considered as an alternative or adjunct to topical corticosteroids 3

Potency-Specific Safety Considerations

Mild to Moderate Potency Steroids (Preferred)

• No increased risk of congenital abnormalities, orofacial clefts, preterm delivery, or low Apgar scores 4, 5
• No association with low birth weight 4, 5
• May actually have a protective effect against fetal death (RR 0.70,95% CI 0.64-0.77) 4

Potent to Very Potent Steroids (Use Cautiously)

• Associated with increased risk of fetal growth restriction, particularly with high cumulative doses 4, 5
• Three individual studies showed increased risk of low birth weight with potent/very potent formulations 4
• Should be avoided unless absolutely necessary, and only after careful risk-benefit assessment 5

Second-Line Options for Inadequate Response

Phototherapy

• UV-light therapy (narrowband UVB) can be considered if topical treatments are insufficient 3
• Safe option during pregnancy when systemic therapy needs to be avoided 3

Systemic Therapy (Severe Disease Only)

When topical treatments and phototherapy fail:

• Cyclosporine A is the first-line systemic treatment option for severe eczema in pregnancy 3
• Azathioprine may be continued in patients already receiving it prior to pregnancy 3
• If systemic corticosteroids are required, use prednisolone specifically - it is 90% inactivated by the placenta, making it the safest option 1, 2
• Avoid betamethasone and dexamethasone as they cross the placenta more readily 1, 2

Medications to Avoid

Contraindicated

• Methotrexate is absolutely contraindicated 3
• Mycophenolate mofetil is contraindicated 3
• Hydroxyzine is specifically contraindicated in early pregnancy 2
• Systemic azole antifungals in first trimester (use topical nystatin if fungal infection suspected) 1, 2

Not Recommended

• Systemic JAK inhibitors are not recommended 3
• Dupilumab is not generally recommended due to lack of human pregnancy data, though some case reports are emerging 3

Antihistamines for Pruritus (If Needed)

• Chlorphenamine (chlorpheniramine) is the preferred antihistamine due to its long safety record 2
• Loratadine and cetirizine are FDA Pregnancy Category B alternatives with no evidence of fetal harm 2

Critical Pitfalls to Avoid

• Do not start with very potent topical corticosteroids - moderate potency is sufficient and safer 1, 2
• Do not use prolonged courses of high-potency topical corticosteroids, especially with large body surface area involvement 1, 2
• Do not prescribe systemic corticosteroids other than prednisolone if escalation is needed 1, 2
• Avoid large cumulative doses of potent topical corticosteroids throughout pregnancy due to fetal growth restriction risk 4, 5

Treatment Algorithm by Severity

Mild flare: Emollients + moderate-potency topical corticosteroids 1, 2, 3

Moderate flare not responding: Add topical tacrolimus or consider phototherapy 3

Severe flare requiring systemic therapy: Cyclosporine A as first choice, with dermatology specialist involvement 3, 6