What are the treatment options for a patient with severe eczema?

Treatment of Severe Eczema

For severe eczema, initiate treatment with potent topical corticosteroids applied once daily, combined with liberal emollient use, and refer to dermatology for consideration of second-line systemic therapies if inadequate response occurs after 4 weeks. 1, 2

First-Line Treatment: Potent Topical Corticosteroids

Potent topical corticosteroids are the cornerstone of severe eczema treatment and should be started immediately. 1, 3

• Apply potent topical corticosteroids (such as betamethasone dipropionate or mometasone furoate) once daily to affected areas—once daily application is equally effective as twice daily for potent steroids and improves adherence 2, 3
• Network meta-analysis demonstrates potent TCS achieve treatment success in approximately 70% of patients versus 39% with mild potency steroids (OR 3.71,95% CI 2.04-6.72) 2
• Very potent corticosteroids (clobetasol propionate 0.05%) rank among the most effective treatments (OR 8.34,95% CI 4.73-14.67 for treatment success) and may be considered for short courses in the most severe cases 3, 4
• Use the least potent preparation that controls symptoms, but do not undertreate severe disease with inappropriately weak steroids 1

Critical caveat: Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is highest 1

Essential Adjunctive Therapy: Aggressive Emollient Use

• Apply emollients liberally and frequently, even when eczema appears controlled—this is the cornerstone of maintenance therapy 1
• Apply emollients immediately after bathing to provide a surface lipid film that retards water loss 1
• Use soap-free cleansers and avoid alcohol-containing products 1

Managing Complications in Severe Eczema

Secondary Bacterial Infection

• Watch for increased crusting, weeping, or pustules indicating Staphylococcus aureus superinfection 1
• Prescribe flucloxacillin as first-line oral antibiotic (or erythromycin if penicillin-allergic) 1, 5
• Continue topical corticosteroids during infection when appropriate systemic antibiotics are given concurrently—do not withhold steroids 1

Eczema Herpeticum (Medical Emergency)

• Suspect if grouped vesicles, punched-out erosions, or sudden deterioration with fever occur 1
• Initiate oral acyclovir immediately; use intravenous acyclovir in ill, febrile patients 1

Pruritus Management

• Prescribe sedating antihistamines (diphenhydramine, hydroxyzine) for nighttime itching through sedative properties, not anti-pruritic effects 1, 6
• Non-sedating antihistamines have no value in atopic eczema and should not be used 1

Second-Line Treatments for Refractory Severe Eczema

If severe eczema fails to respond to optimized first-line therapy after 4 weeks, refer to dermatology for second-line options. 1

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% ranks among the most effective treatments (OR 5.06,95% CI 3.59-7.13 for treatment success) with effectiveness similar to potent TCS 3
• Major advantage: No risk of skin atrophy, making it ideal for face, neck, and flexures 5, 7
• Major disadvantage: Application-site burning/stinging is common (OR 2.2,95% CI 1.53-3.17 versus vehicle), which may limit tolerability 3
• Pimecrolimus 1% is less effective than tacrolimus 0.1% but may be better tolerated 8, 3

FDA Black Box Warning: Long-term safety is unknown; rare cases of malignancy reported (though causal link not established). Use only on eczematous skin, not continuously, and not in children under 2 years 8

JAK Inhibitors (Newer Option)

• Ruxolitinib 1.5% ranks as one of the most effective treatments (OR 9.34,95% CI 4.8-18.18 for treatment success) 3
• Delgocitinib 0.5% and 0.25% also rank among the most effective (OR 10.08 and 6.87 respectively) 3
• These agents have effectiveness comparable to potent/very potent TCS 3

Phototherapy

• Narrowband UVB (312 nm) is an effective option for widespread severe eczema 1
• PUVA therapy shows 81-86% improvement rates in severe cases 5
• Concern: Long-term risk of premature skin aging and cutaneous malignancies, particularly with PUVA 1

Third-Line Treatment: Systemic Therapy

Systemic corticosteroids have a limited but definite role only for "tiding over" occasional patients during acute severe flares after all other options are exhausted. 9, 1

• Never use systemic steroids for maintenance treatment—they should only bridge acute crises 9
• The decision to use systemic steroids should never be taken lightly due to risks of pituitary-adrenal suppression and steroid-related mortality 1
• Other systemic options (cyclosporine, azathioprine, mycophenolate mofetil) are experimental and should be managed by specialists 9, 7

Proactive (Weekend) Therapy to Prevent Relapses

Once severe eczema is controlled, implement twice-weekly (weekend) application of topical corticosteroids to previously affected areas to prevent flares. 1, 2

• This "proactive therapy" reduces relapse risk from 58% to 25% (RR 0.43,95% CI 0.32-0.57) 2
• Continue liberal emollient use daily 1
• No evidence of increased skin thinning with this intermittent approach 2

When to Refer to Dermatology

Refer immediately if: 1

• Failure to respond to potent topical corticosteroids after 4 weeks
• Suspected eczema herpeticum (medical emergency)
• Need for systemic therapy or phototherapy
• Diagnostic uncertainty

Common Pitfalls to Avoid

• Undertreatment due to steroid phobia: Patients and parents often fear topical steroids, leading to inadequate treatment—explain that short-term use of appropriate potency steroids is safe and necessary 1
• Withholding steroids during infection: Continue topical corticosteroids when appropriate antibiotics are given for bacterial superinfection 1
• Continuous use without breaks: Implement "steroid holidays" when possible to minimize adverse effects 1
• Using mild steroids for severe disease: This leads to treatment failure—match steroid potency to disease severity 2, 3