What is the recommended treatment for a patient with dry skin eczema?

Treatment of Dry Skin Eczema (Atopic Dermatitis)

Liberal and regular application of emollients is the cornerstone of treatment for dry skin eczema and should be applied even when the skin appears controlled, combined with topical corticosteroids as first-line therapy for active flares. 1, 2

Essential Emollient Therapy (Foundation of All Treatment)

• Apply emollients liberally and frequently throughout the day to all affected areas, not just visible lesions. 1, 2 This creates a surface lipid film that prevents transepidermal water loss, which is the fundamental defect in eczema. 1, 3

• Apply emollients immediately after bathing to damp skin to maximize hydration and lock in moisture. 1, 3, 2 This timing is critical—waiting even 5-10 minutes significantly reduces effectiveness.

• Use soap-free cleansers or dispersible creams as soap substitutes instead of regular soap, which strips natural lipids and worsens the already compromised skin barrier. 1, 3, 2 Traditional soaps and detergents remove the protective lipid layer that eczema patients desperately need to preserve. 1

• Bathe regularly with lukewarm water for both cleansing and hydrating the skin. 1, 2 Patients should be allowed to decide on the most suitable bath oil and bathing regimen based on their preferences. 1

First-Line Anti-Inflammatory Treatment

• Apply topical corticosteroids once daily (not twice daily) to active eczema lesions using the least potent preparation that controls symptoms. 1, 2, 4 Recent evidence shows once-daily application is as effective as twice-daily with better adherence. 4

• For body eczema, start with moderate-potency topical corticosteroids (such as triamcinolone 0.1% or mometasone 0.1%). 2 For facial or thin-skinned areas, use only low-potency preparations like hydrocortisone 1%. 3

• Implement "steroid holidays"—stop corticosteroids for short periods once symptoms improve to minimize pituitary-adrenal suppression and local side effects like skin atrophy. 3, 2 This means using corticosteroids intermittently rather than continuously.

• Consider the "get control then keep control" regimen: use topical corticosteroids daily until lesions clear, then apply twice weekly to previously affected areas as maintenance to prevent flares. 4 This proactive approach is more effective than reactive treatment.

Alternative Anti-Inflammatory Agents

• Topical calcineurin inhibitors (pimecrolimus or tacrolimus) can be used in conjunction with topical corticosteroids, particularly for sensitive sites like the face, neck, and flexures where corticosteroid atrophy risk is highest. 2, 5, 4 These agents do not cause skin atrophy and can be used for longer periods. 5

• However, note that pimecrolimus carries a black box warning regarding potential cancer risk with long-term use, though causation has not been established. 6 Use only on areas with active eczema, not as a preventive measure on normal skin. 6

Managing Secondary Bacterial Infection

• Watch for signs of bacterial superinfection: increased crusting, weeping, pustules, or sudden worsening despite treatment. 1, 3, 2 Staphylococcus aureus colonizes 90% of eczema lesions and frequently causes secondary infection. 1

• Prescribe oral flucloxacillin as first-line antibiotic for suspected S. aureus infection. 3, 2 Bacteriological swabs are not routinely needed but may help if patients fail to respond. 1

• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—infection is not a contraindication to topical steroid use. 3, 2 This is a common pitfall; many clinicians mistakenly withhold steroids when infection is present.

• Do not use topical or oral antistaphylococcal treatments for infected eczema—there is little evidence supporting their effectiveness. 4 Systemic antibiotics are required for true infection.

Managing Viral Superinfection (Eczema Herpeticum)

• Suspect eczema herpeticum if you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever. 1, 2 This is a dermatological emergency requiring immediate treatment.

• Initiate oral acyclovir immediately in the early disease course. 2 For ill, febrile patients, administer acyclovir intravenously. 2

Managing Pruritus

• Sedating antihistamines (hydroxyzine or diphenhydramine) may help with nighttime itching through their sedative properties, not through direct anti-pruritic effects. 3, 2 Reserve for nighttime use during severe flares only. 3

• Do not prescribe non-sedating antihistamines—they have no value in atopic eczema and should not be used. 2, 4 This is supported by high-quality evidence showing they do not reduce pruritus in eczema patients.

• Keep nails short to minimize trauma from scratching. 1

Avoidance of Aggravating Factors

• Avoid extremes of temperature; use tepid water rather than hot water for bathing. 1

• Avoid irritant clothing such as wool next to the skin; cotton clothing is more comfortable and recommended. 1

• Avoid all alcohol-containing preparations, as they worsen dryness and can trigger flares. 3

Critical Pitfalls to Avoid

• Do not undertreat due to "steroid phobia." 3, 2 Explain to patients that appropriate short-term use of topical corticosteroids is safer than chronic undertreated inflammation, which leads to lichenification and permanent skin changes. 3

• Never delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given concurrently. 3, 2

• Do not use emollient bath additives—large trials show no benefit for eczema patients. 4

• Do not prescribe probiotics for treating eczema—there is insufficient evidence to support their use. 4

When to Refer to Dermatology

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks of appropriate use. 3, 2

• Suspected eczema herpeticum (refer emergently). 3, 2

• Need for systemic therapy (such as phototherapy, cyclosporine, or newer biologics like dupilumab) for severe disease. 2, 5, 7

• Diagnostic uncertainty or atypical presentation requiring biopsy or patch testing. 1

Patient Education Essentials

• Allow adequate time for explanation and demonstration of proper application techniques. 1 A practice or clinic nurse should demonstrate how to apply treatments, and patients should receive written information. 1

• Educate patients on the quantity to use: for emollients, use generous amounts (at least 250-500g per week for an adult with widespread eczema). 1, 8

• Explain that eczema is a chronic condition requiring ongoing maintenance, not just treatment of flares. 5, 8 The goal is to become an "expert patient" who can self-manage effectively. 8