What's the best course of treatment for a patient with eczema on the abdomen and flexural surfaces that's not responding to low-dose steroids and has been treated with Selsun Blue (selenium sulfide)?

Management of Refractory Eczema on Abdomen and Flexural Surfaces

Immediately discontinue Selsun Blue (selenium sulfide), as it has no role in eczema treatment and may be causing irritant contact dermatitis, then escalate to a potent topical corticosteroid such as mometasone furoate 0.1% ointment or triamcinolone acetonide 0.1% cream applied twice daily to all affected areas, combined with aggressive emollient therapy to the entire body. 1, 2

Critical First Step: Stop Inappropriate Treatment

• Selenium sulfide (Selsun Blue) is an antifungal/antiseborrheic agent with no evidence-based role in eczema management and should be discontinued immediately 1
• The application of this inappropriate treatment may be causing additional irritant contact dermatitis, worsening the underlying eczema 3

Escalate Topical Corticosteroid Potency

When low-potency steroids fail, the evidence strongly supports escalating to potent (Class III-IV) topical corticosteroids:

• Potent topical corticosteroids result in a large increase in treatment success compared to mild-potency agents (70% vs 39% achieving clearance or marked improvement) 2
• Mometasone furoate 0.1% ointment or fatty cream is specifically recommended by the American Academy of Dermatology for moderate-to-severe eczema 1
• Triamcinolone acetonide 0.1% cream is an appropriate alternative potent corticosteroid for body and flexural areas 4, 5
• Apply twice daily to all affected areas—incomplete treatment of the entire eczematous area leads to treatment failure 5

Essential Concurrent Measures

Barrier restoration is as critical as anti-inflammatory treatment:

• Apply fragrance-free emollients liberally to the entire body at least once daily, not just affected areas, to restore barrier function 1
• Use soap-free cleansers exclusively to avoid further lipid stripping 1, 6
• Apply emollients immediately after bathing for maximum penetration 1

Evaluate for Secondary Infection

Treatment failure often indicates bacterial superinfection:

• Staphylococcus aureus colonization/infection commonly causes topical corticosteroid resistance 3, 6
• If clinical signs of infection are present (crusting, weeping, honey-colored exudate), add flucloxacillin as first-line antibiotic 3, 1
• Erythromycin is appropriate for penicillin allergy or flucloxacillin resistance 3
• Antibiotics should be given before or concurrent with corticosteroid therapy when infection is present 6

Application Frequency and Duration

• Twice daily application is standard, though once daily application of potent corticosteroids is probably equally effective (no significant difference in treatment success) 2
• Continue treatment until complete clearance is achieved—partial treatment leads to persistent active eczema 5
• Reassess after 2 weeks; if no improvement, consider referral to dermatology 6

Safety Considerations for Body and Flexural Areas

• Flexural areas (groin, axillae, skin folds) are more prone to atrophic changes than other body areas 7
• However, short-term use (2-6 weeks) of potent topical corticosteroids carries minimal risk of skin thinning—only 0.3% (6/2044) developed thinning with longer-term use 2, 8
• The abdomen tolerates potent corticosteroids well with appropriate monitoring 1
• For flexural areas specifically, monitor more closely but do not avoid treatment—undertreating leads to chronic disease 5

Maintenance Strategy After Clearance

Once control is achieved, transition to proactive maintenance:

• Apply mometasone furoate twice weekly to previously affected areas for up to 36 weeks to prevent relapses (68% remission rate over 36 weeks) 1
• Weekend (proactive) therapy results in a large decrease in relapse likelihood from 58% to 25% 2
• Continue daily emollient use indefinitely 1

When to Refer

• Failure to respond after 2-4 weeks of appropriate potent topical corticosteroid therapy warrants dermatology referral 6
• Consider patch testing if contact allergen exposure is suspected 6

Common Pitfalls to Avoid

• Insufficient application area: Treat the entire affected area, not just the most visible portions 5
• Premature discontinuation: Continue until complete clearance, not just improvement 5
• Steroid phobia: The risk of skin thinning with short-term potent corticosteroids is very low (1% across trials), and undertreating leads to worse outcomes 2
• Ignoring infection: Secondary bacterial infection is a common cause of treatment failure and must be addressed 3, 6