What is the first line of treatment for a patient with eczema?

First-Line Treatment for Eczema

The first-line treatment for eczema consists of liberal daily emollient application combined with mild-to-moderate potency topical corticosteroids applied once daily to affected areas during flare-ups. 1

Foundation: Emollient Therapy (Essential for All Patients)

• Apply emollients liberally and frequently throughout the day to maintain skin hydration and improve barrier function—this is the cornerstone of all eczema management 1
• Apply emollients immediately after bathing while skin is still slightly damp to maximize moisture retention and therapeutic benefit 1
• Replace regular soaps with soap-free cleansers or dispersable cream substitutes to prevent removal of natural skin lipids that worsen the condition 1, 2

Anti-Inflammatory Treatment: Topical Corticosteroids

When active eczema is present, start topical corticosteroids as first-line anti-inflammatory therapy, with potency selection based on anatomic location: 1

Potency Selection by Body Location

• Face and intertriginous areas: Use ONLY mild-potency preparations (1% hydrocortisone) to avoid skin atrophy and other complications 1, 2
• Body and extremities: Use mild-to-moderate potency preparations 1, 3
• Infants: Use ONLY mild-potency preparations (1% hydrocortisone) due to high body surface area-to-volume ratio that increases systemic absorption risk 2

Application Strategy

• Apply once daily to affected areas—this is as effective as twice daily application for potent topical corticosteroids 4
• Continue application for short periods until the flare resolves, typically 2-6 weeks 1, 3
• Use the least potent preparation required to control the eczema to minimize side effect risk 5, 1

The evidence strongly supports once-daily application: a Cochrane review pooling 15 trials (1821 participants) found that applying potent topical corticosteroids once daily produces similar treatment success rates compared to twice daily application (OR 0.97,95% CI 0.68 to 1.38) 4. This is important for improving adherence and reducing unnecessary steroid exposure.

Potency Comparison Evidence

Research demonstrates clear efficacy differences between potencies 4:

• Moderate vs. mild potency: 52% vs. 34% treatment success (OR 2.07)
• Potent vs. mild potency: 70% vs. 39% treatment success (OR 3.71)
• Potent vs. moderate potency: No significant difference (OR 1.33, CI 0.93-1.89)

This evidence indicates that potent and moderate topical corticosteroids are more effective than mild preparations for moderate-to-severe eczema, but there is no clear advantage of potent over moderate potency 4.

Alternative First-Line Option

• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) can be used in conjunction with topical corticosteroids as first-line treatment, particularly for sensitive areas where steroid side effects are concerning 1, 6

Proactive Maintenance After Flare Resolution

After achieving disease control, transition to proactive maintenance therapy rather than waiting for the next flare: 1, 2

• Continue applying topical corticosteroids 1-2 times weekly OR topical calcineurin inhibitors 2-3 times weekly to previously affected areas 1
• Continue daily emollient use to all areas 2
• This proactive approach reduces relapse risk from 58% to 25% (RR 0.43) compared to reactive treatment only 2, 4

The rationale for proactive therapy is that clinically normal-appearing skin in eczema patients has persistent subclinical inflammation and barrier defects 2, 7. This represents a significant shift from purely reactive treatment and is strongly recommended by current guidelines 1.

Adjunctive Measures During Severe Flares

• Sedating antihistamines may provide short-term benefit during severe flares primarily through their sedative properties to improve sleep, not through direct antipruritic effects 5, 1, 2
• Non-sedating antihistamines have little to no value in atopic eczema management 5, 1, 2
• Monitor for secondary bacterial infection (crusting, weeping, discharge) which requires appropriate antibiotic treatment—flucloxacillin is usually most appropriate for Staphylococcus aureus 5, 2
• Watch for viral infections, particularly eczema herpeticum, which requires prompt oral acyclovir (or IV if patient is febrile/ill) 5, 2

Critical Pitfalls to Avoid

• Never use potent topical corticosteroids on the face—this leads to skin atrophy and other serious complications 1
• Do not perform routine allergy testing without clinical history suggesting specific allergies 1
• Do not implement food elimination diets based solely on allergy test results without documented clinical reactions 1
• Do not continue ineffective first-line treatment beyond 2-6 weeks—escalate therapy or refer to dermatology 1, 3

When to Refer to Dermatology

Refer when any of the following occur 1, 3, 2:

• Failure to respond to first-line treatment after appropriate trial (2-6 weeks)
• Diagnostic uncertainty
• Second-line treatments (phototherapy, systemic agents) are being considered
• Disease significantly impacts quality of life despite appropriate first-line therapy

Safety Profile of Topical Corticosteroids

Abnormal skin thinning is rare with appropriate first-line use: only 26 cases identified from 2266 participants (1%) across 22 trials 4. Most cases occurred with higher-potency preparations (16 with very potent, 6 with potent, 2 with moderate, 2 with mild) 4. In proactive maintenance trials lasting up to one year, no cases of abnormal skin thinning were identified in 1050 participants 4.