What is the recommended treatment for a patient with eczema, specifically regarding topical corticosteroid (steroid) creams?

Treatment of Eczema with Topical Corticosteroid Creams

Topical corticosteroids are the mainstay of treatment for eczema and should be used as first-line therapy, applied no more than twice daily using the least potent preparation that controls symptoms. 1, 2

Selecting the Appropriate Potency

Start with moderate-potency topical corticosteroids (such as clobetasone butyrate 0.05% or betamethasone valerate 0.025%) for most cases of eczema, as they are significantly more effective than mild-potency options like hydrocortisone 1%. 1, 3

• Moderate-potency corticosteroids result in treatment success (cleared or marked improvement) in 52% of patients versus only 34% with mild-potency preparations 3
• Potent corticosteroids achieve even higher success rates (70% versus 39% with mild preparations) for moderate-to-severe eczema 3
• Reserve very potent corticosteroids (like clobetasol propionate 0.05%) only for severe, recalcitrant cases that fail to respond to less potent options, and use with extreme caution for limited periods only 1, 4

Application Frequency and Technique

Apply topical corticosteroids once daily rather than twice daily—both frequencies are equally effective for potent corticosteroids. 3

• Once daily application achieves the same treatment success as twice daily (no significant difference in outcomes) 3
• Apply as a thin film to affected areas only 1, 5
• Treatment should not be applied more than twice daily even for less potent preparations 1

Essential Adjunctive Emollient Therapy

Liberal emollient use is the cornerstone of eczema management and must be applied regularly, even when eczema appears controlled. 1, 2

• Apply emollients after bathing to provide a surface lipid film that retards water loss 1, 2
• Use soap-free cleansers (dispersible creams as soap substitutes) instead of regular soaps that strip natural skin lipids 1, 2
• Patients should use 200-400 grams of emollient per week when applied twice daily 1
• If using both emollients and corticosteroids, apply the emollient after the corticosteroid cream 1, 2

Duration and Steroid Holidays

Use topical corticosteroids for short periods to control flares, then stop when signs and symptoms (itching, rash, redness) resolve, implementing "steroid holidays" whenever possible. 1, 2, 6

• Very potent and potent corticosteroids should be used with caution for limited periods only 1
• The basic principle is to use the least potent preparation required to keep eczema under control, stopping for short periods when possible 1
• Do not use topical corticosteroids continuously without breaks 2

Proactive (Weekend) Therapy to Prevent Relapses

For patients with frequent flares, apply topical corticosteroids twice weekly (weekend/proactive therapy) to previously affected areas to prevent relapses, which reduces flare likelihood from 58% to 25%. 3

• This proactive approach is significantly more effective than reactive treatment (applying only when flares occur) 3
• Continue this maintenance strategy for 16-20 weeks or longer as needed 3

Managing Secondary Bacterial Infection

Continue topical corticosteroids even when bacterial infection is present, but add appropriate systemic antibiotics concurrently. 1, 7, 2

• Watch for signs of bacterial superinfection: increased crusting, weeping, pustules, or failure to respond to treatment 1, 2
• Prescribe oral flucloxacillin as first-line treatment for Staphylococcus aureus, the most common pathogen 1, 7, 2
• Use phenoxymethylpenicillin if beta-hemolytic streptococci are isolated 1
• Erythromycin is appropriate for penicillin allergy or flucloxacillin resistance 1

Recognizing Eczema Herpeticum (Medical Emergency)

If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum and initiate oral acyclovir immediately—this is a medical emergency. 1, 7, 2

• Start acyclovir early in the disease course 1, 2
• In ill, feverish patients, administer acyclovir intravenously 1, 2

Location-Specific Precautions

Avoid very potent or potent corticosteroids around the eyes, face, neck, flexures, and genitals due to high risk of skin atrophy in these thin-skinned areas. 7

• For periocular (eyelid) eczema, use only low-to-moderate potency corticosteroids applied twice daily maximum 7
• Consider tacrolimus 0.03% ointment as second-line therapy for severe eyelid eczema refractory to topical corticosteroids 7

Safety Profile and Adverse Events

Abnormal skin thinning from topical corticosteroids is rare when used appropriately, occurring in only 1% of patients (26 cases from 2266 participants across trials), with most cases from very potent preparations. 3

• Long-term intermittent use (up to 5 years) of mild-to-moderate potency corticosteroids results in little to no difference in growth abnormalities, infections, or malignancies compared to non-corticosteroid treatments 8
• The main risk with prolonged use of potent/very potent preparations is pituitary-adrenal axis suppression with possible growth interference in children 1
• Systemic absorption is negligible with appropriate use of mild-to-moderate potency preparations 9

Addressing Patient Fears and Ensuring Compliance

Explain to patients that 72.5% of people worry about topical corticosteroids (particularly skin thinning), but these fears are out of proportion to actual evidence of harm, and such fears lead to undertreatment in 24% of patients. 10

• Clearly explain the different potencies available and the benefits versus risks of each 1, 10
• Emphasize that when used as directed (appropriate potency, short-term for flares, with steroid holidays), topical corticosteroids are safe and effective 1, 8
• Many patients incorrectly classify hydrocortisone as "strong" when it is actually the mildest preparation 10

Adjunctive Treatments for Pruritus

Sedating antihistamines (not non-sedating types) may help with nighttime itching through their sedative properties during severe flares, but they have little direct anti-pruritic effect and should only be used short-term. 1, 2

• Non-sedating antihistamines have little to no value in atopic eczema 1, 2
• The therapeutic value resides principally in sedative properties, not antihistamine effects 1
• Value may be progressively reduced due to tachyphylaxis 1

Common Pitfalls to Avoid

• Never delay topical corticosteroids when infection is present—they remain primary treatment when appropriate systemic antibiotics are given concurrently 2
• Do not use hydrocortisone 1% for body eczema—it is often ineffective outside facial eczema and moderate-potency preparations are needed 9
• Do not apply corticosteroids more than twice daily—increased frequency does not improve outcomes 1, 3
• Avoid occlusive dressings unless specifically treating psoriasis or recalcitrant conditions, and discontinue if infection develops 5