What are the treatment options for a patient with eczema?

Treatment for Eczema

Start with liberal emollients applied multiple times daily combined with topical corticosteroids as first-line therapy, using the least potent preparation that controls symptoms—typically mild potency (1% hydrocortisone) for mild disease, moderate potency for moderate disease, and potent preparations for severe disease or thick-skinned areas like hands and feet. 1

First-Line Treatment Algorithm

Step 1: Emollient Foundation

• Apply emollients liberally and frequently throughout the day, even when skin appears clear, as this is the cornerstone of maintenance therapy 1, 2
• Apply immediately after bathing to lock in moisture and provide a protective lipid barrier that prevents water loss 1, 3
• Use soap-free cleansers exclusively and avoid alcohol-containing products 1, 2

Step 2: Topical Corticosteroid Selection by Severity and Location

• Mild eczema or facial/flexural areas: Start with mild potency corticosteroids (1% hydrocortisone) applied no more than twice daily 1, 2
• Moderate eczema: Use moderate potency corticosteroids, which are probably more effective than mild preparations (52% vs 34% treatment success) 1, 4
• Severe eczema or thick-skinned areas (hands/feet): Use potent corticosteroids like clobetasol propionate 0.05% or mometasone furoate, which result in large increases in treatment success (70% vs 39% compared to mild potency) 1, 3, 4
• Apply once daily—this is equally effective as twice daily application for potent corticosteroids 5

Critical caveat: Very potent and potent corticosteroids should be used with caution for limited periods only, with short "steroid holidays" when possible 1. Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is higher 1.

Step 3: Application Technique

• Apply topical corticosteroids to affected areas only, not as a preventive measure on clear skin 1
• If using moisturizers, apply corticosteroids first, then emollients after 3
• Stop corticosteroids when symptoms (itching, rash, redness) resolve or as directed 1

Managing Pruritus

• Prescribe sedating antihistamines (like diphenhydramine) exclusively at nighttime for severe itching—their benefit comes from sedation, not direct anti-pruritic effects 1, 3
• Do not use non-sedating antihistamines—they have little to no value in atopic eczema 1

Identifying and Treating Secondary Infections

Bacterial Infection (Staphylococcus aureus)

• Watch for increased crusting, weeping, or pustules indicating bacterial superinfection 1, 2, 3
• Start oral flucloxacillin as first-line antibiotic 1, 2, 3
• Continue topical corticosteroids during infection—do not delay or withhold them when appropriate systemic antibiotics are given concurrently 1, 2

Eczema Herpeticum (Medical Emergency)

• Suspect if you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever 1, 2
• Initiate oral acyclovir immediately and early in the disease course 1, 2
• Use IV acyclovir if patient is ill or febrile 1, 2

Proactive (Weekend) Maintenance Therapy

After achieving control, consider proactive therapy to prevent relapses:

• Apply topical corticosteroids twice weekly (weekend therapy) to previously affected sites 3
• This probably results in a large decrease in relapse likelihood from 58% to 25% 5
• Continue aggressive emollient use daily 1, 3

Second-Line Treatments (After Topical Corticosteroid Failure)

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% and pimecrolimus 1% are options after other prescription medicines have failed 6, 4, 7
• Only approved for children 2 years and older—not appropriate for babies under 2 years 2, 6
• Most common side effect is application-site burning or warmth, usually mild to moderate, occurring in first 5 days 6, 4
• Use only on areas with eczema, for short periods with breaks in between 6
• Black box warning: Long-term safety unknown; very small number of users developed cancer (skin or lymphoma), though causal link not established 6
• Avoid continuous long-term use 6

JAK Inhibitors

• Ruxolitinib 1.5% and delgocitinib 0.5% or 0.25% are ranked among the most effective treatments, comparable to potent topical corticosteroids 4, 7

Phototherapy

• Narrow band ultraviolet B (312 nm) is an option for moderate-to-severe disease 1
• Concern exists about long-term adverse effects including premature skin aging and cutaneous malignancies, particularly with PUVA 1

Systemic Therapy (Severe Disease Only)

• Oral corticosteroids have a limited but definite role for "tiding over" occasional patients during acute severe flares requiring rapid control when topical therapy has failed 1
• Should not be used for maintenance treatment or to induce stable remission 1
• Significant risks include pituitary-adrenal suppression and corticosteroid-related mortality 1
• Consider cyclosporine A or mycophenolate mofetil for severe cases 8

Safety Profile: Skin Thinning with Topical Corticosteroids

• Short-term use (median 3 weeks): No evidence of increased skin thinning with any potency of topical corticosteroids 1, 5
• Longer-term use (6-60 months): Increased skin thinning reported in 6/2044 (0.3%) participants using mild to potent topical corticosteroids 4, 7
• In short-term trials reporting abnormal skin thinning, only 26 cases occurred among 2266 participants (1%), with most cases from higher-potency preparations (16 with very potent, 6 with potent) 5

When to Refer or Escalate

• Failure to respond to moderate potency topical corticosteroids after 4 weeks 1, 2
• Any suspicion of eczema herpeticum (immediate referral) 1, 2
• Need for systemic therapy or phototherapy 1, 3
• Symptoms do not improve after 6 weeks of treatment 6

Critical Pitfalls to Avoid

• Parental steroid phobia: Explain that mild preparations like hydrocortisone have favorable safety profiles when used appropriately—undertreatment from fear of steroids is common 1, 2
• Withholding corticosteroids during infection: Continue topical corticosteroids as primary treatment when appropriate antibiotics are given 1, 2, 3
• Continuous use without breaks: Implement "steroid holidays" when possible to minimize side effects 1, 2
• Using potent preparations on thin skin: Avoid very potent corticosteroids on face, neck, flexures, and genitals 1

Special Population: Babies Under 2 Years

• Use 1% hydrocortisone as first-line topical corticosteroid, FDA-approved under physician supervision 2
• Do not use topical calcineurin inhibitors—only approved for children 2 years and older 2, 6
• Consider wet-wrap therapy before systemic immunosuppression if failing conventional topical therapy 2