Eczema Management
First-Line Treatment: Topical Corticosteroids Plus Emollients
Start with topical corticosteroids as the mainstay of treatment, using the least potent preparation that controls symptoms, applied no more than twice daily to affected areas, combined with liberal emollient use. 1
Selecting Corticosteroid Potency by Body Site
For hands and feet: Use potent topical corticosteroids (clobetasol propionate 0.05% or mometasone furoate) twice daily, as these areas have thicker skin that tolerates higher potency steroids 2
For thin-skinned areas (face, neck, behind ears, flexures, genitals): Start with mild to moderate potency corticosteroids (hydrocortisone 1-2.5% or prednicarbate 0.02%) to minimize atrophy risk 3, 1
For trunk and extremities: Moderate to potent corticosteroids are appropriate based on severity 1
Evidence shows: Potent topical corticosteroids result in 70% treatment success versus 39% with mild potency (OR 3.71,95% CI 2.04 to 6.72), while moderate potency achieves 52% versus 34% with mild potency (OR 2.07,95% CI 1.41 to 3.04) 4, 5
Application Frequency
Apply topical corticosteroids once daily rather than twice daily—both frequencies are equally effective. 6, 7
- Once daily application achieves similar treatment success compared to twice daily use (OR 0.97,95% CI 0.68 to 1.38) 6
Essential Emollient Therapy
Apply emollients liberally and frequently throughout the day, immediately after bathing and hand washing, to provide a surface lipid film that retards water loss 1, 2
Continue aggressive emollient use even when eczema appears controlled—this is the cornerstone of maintenance therapy 1, 2
Use soap-free cleansers exclusively and avoid alcohol-containing products 1, 3
Proactive Maintenance Therapy to Prevent Flares
After achieving clearance, apply topical corticosteroids twice weekly (weekend therapy) to previously affected sites to prevent relapse. 2
Weekend proactive therapy reduces relapse likelihood from 58% to 25% (RR 0.43,95% CI 0.32 to 0.57) 6
This strategy is superior to reactive treatment (applying only when flares occur) 6, 7
Managing Pruritus
Prescribe sedating antihistamines (diphenhydramine, clemastine) exclusively at nighttime to help patients sleep through severe itching—their benefit comes from sedation, not direct anti-pruritic effects 1, 2, 3
Do not use non-sedating antihistamines—they have no value in eczema and should be avoided 1, 2, 7
Identifying and Treating Secondary Bacterial Infection
Watch for increased crusting, weeping, or pustules indicating Staphylococcus aureus infection 1, 2
Add oral flucloxacillin as first-line antibiotic while continuing topical corticosteroids—do not delay or withhold corticosteroids when infection is present 1, 2
Critical pitfall: Oral or topical antistaphylococcal treatments for infected eczema lack strong evidence and should be reconsidered 7
Eczema Herpeticum Emergency
If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum 1, 3
Initiate oral acyclovir early; in ill, feverish patients, administer acyclovir intravenously 1, 3
This is a medical emergency requiring immediate treatment 1, 3
Safety Considerations and Steroid Holidays
Implement short "steroid holidays" when possible to minimize side effects, especially with very potent and potent corticosteroids 1
Avoid continuous use without breaks 1
Skin thinning risk: Short-term use (median 3 weeks, range 1-16 weeks) of any topical corticosteroid potency does not increase skin thinning risk 4, 6
However, longer-term use (6-60 months) resulted in skin thinning in 0.3% of participants (6/2044) 4, 5
Abnormal skin thinning occurred in only 1% of participants across short-term trials (26 cases from 2266 participants), mostly with higher potencies 6
Second-Line Treatments for Moderate-to-Severe Disease
Topical Calcineurin Inhibitors
Tacrolimus 0.1% ranks among the most effective treatments, comparable to potent topical corticosteroids 4, 5
Useful for sensitive sites where corticosteroid atrophy risk is higher 7
Important caveat: Tacrolimus 0.1% and pimecrolimus 1% cause more application-site reactions (burning, stinging) than topical corticosteroids (OR 2.2,95% CI 1.53 to 3.17 for tacrolimus 0.1%) 4, 5
JAK Inhibitors
- Ruxolitinib 1.5% and delgocitinib 0.5% or 0.25% rank among the most effective treatments, comparable to potent/very potent topical corticosteroids 4, 5
PDE-4 Inhibitors
Crisaborole 2% and roflumilast 0.15% consistently rank among the least effective topical anti-inflammatory treatments 4, 5
Crisaborole 2% causes application-site reactions (OR 2.12,95% CI 1.18 to 3.81) 4
Phototherapy
For hand and foot eczema failing topical therapy, oral PUVA achieves 81-86% significant improvement or clearance 2
Narrow band ultraviolet B (312 nm) is an option, though concerns exist about long-term adverse effects including premature skin aging and cutaneous malignancies 1
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, 2
Use short-term "tiding over" during crisis periods when topical therapy has failed 1
Critical safety concern: Pituitary-adrenal suppression is a significant risk with prolonged use, and corticosteroid-related mortality has been documented in other inflammatory conditions 1
When to Refer or Escalate
Common Pitfalls to Avoid
Undertreatment due to steroid phobia: Patients' or parents' fears of steroids often lead to inadequate treatment—explain the different potencies and benefits/risks clearly 1
Delaying corticosteroids during infection: Do not withhold topical corticosteroids when infection is present—they remain primary treatment when appropriate systemic antibiotics are given concurrently 1, 2
Using twice daily application unnecessarily: Once daily is equally effective and improves adherence 6, 7
Treatments to Avoid
Probiotics: Little evidence supports their use for treating eczema 7
Emollient bath additives: Have not been shown to benefit eczema patients 7
Silk clothing and ion-exchange water softeners: Lack evidence of benefit 7
Emollients from birth for prevention: Large trials show they do not prevent eczema and may increase skin infections and food allergy 7