What is the recommended treatment approach for a patient with eczema?

Treatment of Eczema (Atopic Dermatitis)

Start with topical corticosteroids as first-line therapy, applying them 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

Topical Corticosteroid Selection by Body Site and Severity

For trunk and extremities with moderate-to-severe eczema:

• Use potent topical corticosteroids (such as clobetasol propionate 0.05% or mometasone furoate) twice daily 2, 3
• Potent corticosteroids are significantly more effective than mild corticosteroids, with 70% versus 39% achieving treatment success 1
• Moderate-potency corticosteroids show 52% versus 34% success compared to mild potency 1

For face, neck, flexures, and genitals:

• Use mild to moderate potency corticosteroids (hydrocortisone 1-2.5% or prednicarbate 0.02%) to minimize atrophy risk 4
• These thin-skinned areas require lower potency due to increased absorption and higher risk of adverse effects 4

For hands and feet:

• Use potent corticosteroids (clobetasol propionate 0.05%) twice daily, as thicker skin tolerates higher potency 2

Application Frequency

Apply topical corticosteroids twice daily initially - once daily application is equally effective as twice daily for potent corticosteroids, but starting with twice daily ensures adequate control 1, 3

Duration and Stopping Rules

• Stop when symptoms resolve (itching, rash, redness disappear) or as directed 1, 5
• Implement "steroid holidays" with short breaks when possible to minimize side effects 1
• Do not use continuously long-term without breaks 1

Essential Adjunctive Measures

Emollient Therapy (Critical Component)

• Apply emollients liberally and frequently throughout the day, even when eczema appears controlled 1, 2
• Apply immediately after bathing to provide a surface lipid film that retards water loss 1, 2
• Use soap-free cleansers exclusively and avoid alcohol-containing products 1, 4
• Regular bathing for cleansing and hydrating is recommended 1
• If using moisturizers with topical corticosteroids, apply emollients after the corticosteroid, not before 1

Managing Pruritus (Itching)

• Prescribe sedating antihistamines exclusively at nighttime (diphenhydramine or clemastine) to help patients sleep through severe itching 1, 2, 4
• The benefit comes from sedation, not direct anti-pruritic effects 1, 2
• Do not use non-sedating antihistamines - they have no value in atopic eczema 1, 2

Managing Secondary Infections

Bacterial Infection (Staphylococcus aureus)

Watch for these specific signs:

• Increased crusting, weeping, or pustules 1, 2

Treatment approach:

• Add oral flucloxacillin as first-line antibiotic 1, 2
• Continue topical corticosteroids during infection when appropriate systemic antibiotics are given concurrently 1
• Do not delay or withhold topical corticosteroids when infection is present 1

Eczema Herpeticum (Medical Emergency)

Recognize these warning signs:

• Grouped vesicles, punched-out erosions, or sudden deterioration with fever 1, 4

Immediate treatment:

• Initiate oral acyclovir early in the disease course 1
• In ill, feverish patients, administer acyclovir intravenously 1, 4

Proactive Maintenance Therapy (Preventing Flare-ups)

After achieving control, apply topical corticosteroids twice weekly (weekend therapy) to previously affected sites to prevent relapse 2, 3

• This reduces relapse likelihood from 58% to 25% 3
• This approach is significantly more effective than reactive use only 3

Second-Line Treatments (When First-Line Fails)

Topical Calcineurin Inhibitors

Pimecrolimus 1% (Elidel) or tacrolimus:

• Use only after topical corticosteroids have failed or when corticosteroids are not recommended 5
• Apply twice daily to affected areas only 5
• Do not use in children under 2 years old 5
• Do not use continuously long-term - use for short periods with breaks in between 5
• Most common side effect is burning or warmth at application site, usually resolving within 5 days 5
• Avoid sun exposure during treatment - do not use sun lamps, tanning beds, or UV therapy 5
• Stop when symptoms resolve or after 6 weeks if no improvement 5

Phototherapy

• Narrow band ultraviolet B (312 nm) is an option for widespread disease 6, 1
• Concern exists about long-term adverse effects including premature skin aging and cutaneous malignancies, particularly with PUVA 6, 1

Third-Line Treatment (Severe Cases Only)

Systemic Corticosteroids

Use only for acute severe flares requiring rapid control when all other options exhausted 1

• Should never be used for maintenance treatment 6, 1
• Reserved for "tiding over" occasional patients during crisis periods 6, 1
• Significant risks include pituitary-adrenal suppression and corticosteroid-related mortality 1

Critical Safety Considerations

Local Adverse Effects

Application-site reactions:

• Tacrolimus 0.1%, crisaborole 2%, and pimecrolimus 1% are most likely to cause burning/stinging 7
• Topical corticosteroids are least likely to cause application-site reactions 7

Skin thinning/atrophy:

• Short-term corticosteroid use (median 3 weeks) shows no evidence of increased skin thinning 7
• Longer-term use (6-60 months) shows increased skin thinning with mild to potent corticosteroids 7
• Risk increases with higher potency preparations 1
• Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) 1

Common Pitfalls to Avoid

• Steroid phobia leads to undertreatment - explain different potencies and benefits/risks clearly to patients 1
• Do not use topical corticosteroids in eyes - rinse with cold water if accidental exposure 5
• Do not bathe, shower, or swim immediately after applying topical treatments - this washes off the medication 5
• Do not cover treated skin with bandages, dressings, or wraps - normal clothing is acceptable 5

When to Refer to Specialist

Refer immediately for:

• Suspected eczema herpeticum (medical emergency) 1

Refer within 6 weeks for:

• Failure to respond to moderate potency topical corticosteroids after 4 weeks 1, 2, 4
• Diagnostic doubt 6
• Need for systemic therapy or phototherapy 1, 2
• Consideration of second-line treatments 6