What is the first line treatment for a patient presenting with eczema?

First-Line Treatment for Eczema

The first-line treatment for eczema consists of aggressive emollient therapy (applied liberally 3-4 times daily to the entire body) combined with topical corticosteroids—using mild potency (1% hydrocortisone) for infants and children, and moderate-to-potent potency for adults—applied twice daily to all affected areas until the flare resolves. 1, 2

Essential Emollient Therapy (Foundation of All Treatment)

• Apply emollients liberally at least 3-4 times daily to the entire body, immediately after bathing while skin is still damp, to trap moisture and restore the skin barrier. 1, 2
• Use thick ointments or creams rather than lotions for maximum occlusion—expect to use 200-400 grams per week for whole body application in adults. 1
• Select fragrance-free formulations to avoid irritation and continue aggressive emollient use even when lesions appear controlled, as this has documented steroid-sparing effects. 1
• Replace regular soaps with soap substitutes (dispersible creams) to prevent removal of natural skin lipids. 2

Topical Corticosteroid Selection and Application

For infants and young children: Use mild-potency topical corticosteroids (1% hydrocortisone) for flare-ups, as infants are particularly susceptible to side effects due to their high body surface area to volume ratio. 2

For adults and older children with whole body involvement: Apply moderate-to-potent topical corticosteroids twice daily to all affected areas, stratifying potency by body region—use potent steroids on trunk and extremities, but step down to moderate potency on thin-skinned areas (face, neck, flexures, genitals) to avoid atrophy. 1

• Use the least potent preparation that achieves control and apply only until the flare resolves (typically 2-4 weeks maximum on the face). 1, 2
• The most recent and highest quality evidence (2024 Cochrane network meta-analysis of 291 trials) confirms potent topical corticosteroids rank among the most effective treatments for eczema, with moderate-to-high confidence in the evidence. 3
• Implement "steroid holidays" (short breaks) when possible to minimize systemic absorption risk and local side effects. 1

Transitioning to Maintenance Therapy

• After achieving flare resolution, transition to proactive maintenance therapy rather than waiting for the next flare—this reduces relapse risk from 58% to 25% (RR 0.43). 2
• Apply topical corticosteroids twice weekly (weekend therapy) to previously affected sites even when skin appears clear, while continuing daily emollient use to all areas. 1, 2
• This proactive approach addresses persistent subclinical inflammation and barrier defects that remain in clinically normal-appearing skin. 2

Managing Pruritus (Itching)

• Prescribe sedating antihistamines (cetirizine, loratadine, fexofenadine, or clemastine) exclusively at nighttime for severe itching during flares, as their benefit comes from sedation rather than direct anti-pruritic effects. 1, 2
• Non-sedating antihistamines have no value in eczema and should not be used. 1, 2
• Urea- or polidocanol-containing lotions can provide additional relief when applied to affected areas. 4

Recognizing and Treating Secondary Infections

Watch for these red flags indicating bacterial superinfection (most commonly Staphylococcus aureus): increased crusting, weeping, pustules, or honey-colored discharge. 1, 2

• Add oral flucloxacillin (or appropriate anti-staphylococcal antibiotic) as first-line treatment while continuing topical corticosteroids—do not delay or withhold steroids when infection is present, as they remain the primary treatment when appropriate systemic antibiotics are given concurrently. 1, 2

Suspect eczema herpeticum if you observe: grouped vesicles, punched-out erosions, or sudden deterioration with fever. 1, 2

• Initiate oral acyclovir immediately if herpes simplex superinfection is suspected. 1, 2

When to Refer to Dermatology

Refer immediately if: 1, 2

• Failure to respond to moderate-to-potent topical corticosteroids after 4 weeks
• Diagnostic uncertainty or atypical presentation
• Need for systemic therapy or phototherapy
• Suspected eczema herpeticum
• Recurrent severe flares despite optimal maintenance therapy

Common Pitfalls to Avoid

• Undertreatment due to fear of steroid side effects—the 2024 Cochrane review found no evidence for increased skin thinning with short-term topical corticosteroid use (median 3 weeks, range 1-16 weeks), though longer-term use (6-60 months) did show increased risk. 3
• Using non-sedating antihistamines, which provide no benefit in eczema. 1, 2
• Applying emollients less frequently than 3-4 times daily—inadequate moisturization undermines all other treatments. 1
• Discontinuing topical corticosteroids too abruptly without transitioning to twice-weekly maintenance therapy. 1, 2

Alternative First-Line Options (When Corticosteroids Are Contraindicated)

Topical calcineurin inhibitors (tacrolimus 0.03-0.1% or pimecrolimus 1%) can be used as first-line treatment in conjunction with or as an alternative to topical corticosteroids, particularly for sensitive areas like the face. 5

• The 2024 Cochrane review ranked tacrolimus 0.1% among the most effective treatments (similar to potent corticosteroids), though it causes more application-site reactions (burning, stinging) during the first few days of treatment. 3
• These agents do not cause skin atrophy, making them preferable for long-term use on the face and other thin-skinned areas. 6, 5