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

Eczema Management

First-Line Treatment: Topical Corticosteroids Plus Emollients

Start with topical corticosteroids as the mainstay of treatment, using the least potent preparation that controls symptoms, applied no more than twice daily to affected areas, combined with liberal emollient use. 1

Selecting Corticosteroid Potency by Body Site

• For hands and feet: Use potent topical corticosteroids (clobetasol propionate 0.05% or mometasone furoate) twice daily, as these areas have thicker skin that tolerates higher potency steroids 2

• For thin-skinned areas (face, neck, behind ears, flexures, genitals): Start with mild to moderate potency topical corticosteroids (hydrocortisone 1-2.5% or prednicarbate 0.02%) to minimize risk of skin atrophy 3

• For trunk and limbs: Moderate to potent topical corticosteroids are appropriate based on severity 1

• Potent topical corticosteroids are more effective than mild potency (70% vs 39% treatment success), and moderate potency is more effective than mild (52% vs 34% treatment success) 4, 5

Application Frequency

Apply topical corticosteroids once daily rather than twice daily - there is no additional benefit from more frequent application of potent topical corticosteroids 1, 6, 7

Essential Emollient Therapy

• Apply emollients liberally and frequently throughout the day, immediately after hand washing and bathing, to provide a surface lipid film that retards water loss 1, 2

• Continue aggressive emollient use even when eczema appears controlled - this is the cornerstone of maintenance therapy 1, 2

• Use soap-free cleansers exclusively and avoid alcohol-containing products 1, 2, 3

Proactive Maintenance Therapy to Prevent Flares

After achieving clearance, apply topical corticosteroids twice weekly (weekend therapy) to previously affected sites to prevent relapse - this reduces flare-ups from 58% to 25% 2, 6

Critical Safety Measures

• Implement short "steroid holidays" when possible to minimize side effects 1

• Very potent and potent corticosteroids should be used with caution for limited periods only 1

• Short-term use (median 3 weeks) of topical corticosteroids does not cause skin thinning, but longer-term use (6-60 months) carries a 0.3% risk of skin atrophy 4, 6

Managing Pruritus (Itching)

• Sedating antihistamines (diphenhydramine, clemastine) may help with nighttime itching exclusively through their sedative properties, not through direct anti-pruritic effects 1, 2, 3

• Non-sedating antihistamines have no value in eczema and should not be used 1, 2, 7

Managing Secondary Bacterial Infection

• Watch for signs of secondary bacterial infection: increased crusting, weeping, or pustules 1, 2, 3

• Add oral flucloxacillin as first-line antibiotic for Staphylococcus aureus while continuing topical corticosteroids - do not delay or withhold corticosteroids when infection is present 1, 2, 3

Eczema Herpeticum - Medical Emergency

• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum 1, 3

• Initiate oral acyclovir early in the disease course 1

• In ill, feverish patients, administer acyclovir intravenously 1, 3

Second-Line Treatments for Moderate-to-Severe Disease

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% is among the most effective topical anti-inflammatory treatments, ranking similarly to potent topical corticosteroids for treatment success 4, 5

• Useful for sensitive sites where corticosteroid side effects are a concern 7

• Application-site reactions are most common with tacrolimus 0.1% and pimecrolimus 1% compared to topical corticosteroids 4, 5

JAK Inhibitors

• Ruxolitinib 1.5% and delgocitinib 0.5% or 0.25% rank among the most effective topical treatments, with similar effectiveness to potent/very potent topical corticosteroids 4, 5

Phototherapy

• Narrow band ultraviolet B (312 nm) is an option for phototherapy 1

• For hand and foot eczema failing topical therapy, oral PUVA is superior to UVB phototherapy, with 81-86% achieving significant improvement 2

• Long-term concerns include premature skin aging and cutaneous malignancies, particularly with PUVA 1

Systemic Therapy - Limited Role

Systemic corticosteroids should only be used for acute severe flares requiring rapid control after exhausting all other options, never for maintenance treatment 1, 2

• Pituitary-adrenal suppression is a significant risk with prolonged use 1

• Corticosteroid-related mortality has been documented, with up to 77% of deaths in pemphigus vulgaris being steroid-related 1

When to Refer or Escalate

• Failure to respond to moderate or potent topical corticosteroids after 4 weeks 1, 2, 3

• Need for systemic therapy or phototherapy 1, 2, 3

• Suspected eczema herpeticum (medical emergency) 1, 3

Common Pitfalls to Avoid

• Do not delay or withhold topical corticosteroids when infection is present - they remain the primary treatment when appropriate systemic antibiotics are given 1, 2

• Patients' or parents' fears of steroids often lead to undertreatment - explain the different potencies and the benefits/risks clearly 1

• Avoid very potent corticosteroids in thin-skinned areas where risk of atrophy is higher 1, 3

• Do not use topical corticosteroids continuously without breaks 1