What is the recommended treatment for a patient with eczema?

Treatment of Eczema (Atopic Dermatitis)

Topical corticosteroids are the first-line treatment for eczema and should be applied twice daily to affected areas using the least potent preparation that controls symptoms, combined with liberal emollient use as the cornerstone of maintenance therapy. 1

First-Line Treatment Algorithm

Step 1: Topical Corticosteroids + Emollients

• Apply topical corticosteroids no more than twice daily to affected areas only, using the least potent preparation that achieves control 1
• Potent and moderate-potency topical corticosteroids are significantly more effective than mild-potency preparations for moderate-to-severe eczema (70% vs 39% treatment success for potent vs mild) 2, 3
• Once daily application of potent topical corticosteroids is as effective as twice daily application, so once daily dosing is sufficient 4
• 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 2: Liberal Emollient Use

• Apply emollients regularly even when eczema appears controlled - this is the cornerstone of maintenance therapy 1
• Apply emollients after bathing to provide a surface lipid film that retards water loss 1
• Use soap-free cleansers and avoid alcohol-containing products 1
• If using moisturizers with topical corticosteroids, apply the emollient after the corticosteroid 1

Managing Pruritus

• Sedating antihistamines may help with nighttime itching through their sedative properties, not through direct anti-pruritic effects 1
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used 1

Managing Secondary Infections

Bacterial Infection

• Watch for increased crusting, weeping, or pustules indicating secondary bacterial infection 1
• Flucloxacillin is first-line oral antibiotic for Staphylococcus aureus, the most common pathogen 1
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently 1

Eczema Herpeticum (Medical Emergency)

• Suspect if you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever 1, 5
• For febrile patients with eczema herpeticum, administer intravenous acyclovir immediately 5
• For non-febrile patients, initiate oral acyclovir early in the disease course 1

Second-Line Treatments

Topical Calcineurin Inhibitors (TCIs)

• Pimecrolimus 1% cream (Elidel) and tacrolimus ointments are second-line options for patients who do not respond adequately to topical corticosteroids or when corticosteroids should not be used 6
• Tacrolimus 0.1% ranks among the most effective treatments, comparable to potent topical corticosteroids 2, 3
• Do not use on children under 2 years old 6
• Use only for short periods with breaks in between, not continuously long-term, due to uncertain long-term safety and rare reports of cancer (though causal link not established) 6
• Apply only to areas with active eczema 6
• Most common side effect is application-site burning or warmth, usually mild-to-moderate, occurring in first 5 days and resolving within a week 6
• TCIs cause significantly more local application-site reactions than topical corticosteroids but do not cause skin thinning 2

JAK Inhibitors

• Ruxolitinib 1.5% ranks among the most effective treatments, comparable to potent topical corticosteroids and tacrolimus 0.1% 2, 3
• Delgocitinib 0.5% and 0.25% also show high effectiveness 2

PDE-4 Inhibitors

• Crisaborole 2% and roflumilast 0.15% are available but rank among the least effective topical anti-inflammatory treatments 2, 3
• Crisaborole 2% causes high rates of application-site reactions (similar to tacrolimus 0.1%) 2

Proactive (Maintenance) Therapy to Prevent Flares

• Apply topical corticosteroids twice weekly (weekend therapy) to previously affected areas even after clearing to prevent relapse 4
• This reduces relapse risk from 58% to 25% over 16-20 weeks 4
• No increased risk of skin thinning observed with this strategy in trials up to 60 months 4

Systemic Therapy for Severe Disease

• Systemic corticosteroids have a limited role only for tiding occasional patients through acute severe flares when topical therapy has failed 1
• Should not be used for maintenance treatment 1
• Narrow band ultraviolet B (312 nm) phototherapy is an option for severe cases 1
• Cyclosporine A or mycophenolate mofetil may be considered for severe refractory cases 7

Safety Considerations

Skin Thinning with Topical Corticosteroids

• Short-term use (median 3 weeks) of any potency topical corticosteroid does not increase skin thinning risk 4
• Abnormal skin thinning occurred in only 1% of participants across trials, with most cases from very potent preparations 4
• Longer-term use (6-60 months) shows increased skin thinning risk (0.3% incidence) 3
• Implement "steroid holidays" when using potent or very potent preparations 1

Application-Site Reactions

• Most common with tacrolimus 0.1%, crisaborole 2%, tacrolimus 0.03%, and pimecrolimus 1% 2
• Least common with topical corticosteroids of all potencies 2

When to Refer or Escalate

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks 1
• Need for systemic therapy or phototherapy 1
• Suspected eczema herpeticum (medical emergency requiring immediate IV acyclovir) 1, 5

Common Pitfalls to Avoid

• Do not delay or withhold topical corticosteroids when infection is present - they remain primary treatment when appropriate systemic antibiotics are given 1
• Do not use topical corticosteroids continuously without breaks - implement "steroid holidays" 1
• Address steroid phobia - patients' or parents' fears often lead to undertreatment; explain different potencies and benefits/risks clearly 1
• Do not use non-sedating antihistamines - they provide no benefit in atopic eczema 1