What is the stepwise management approach for atopic dermatitis (eczema)?

Stepwise Management of Atopic Dermatitis (Eczema)

Begin with liberal emollient therapy and topical corticosteroids as the mainstay of treatment, using the least potent preparation that controls the eczema, then escalate systematically based on disease severity and response. 1

Step 1: Foundation Therapy (All Patients, All Severities)

Emollient Therapy

• Prescribe at least 250 grams per week for adults and apply liberally at least twice daily, most effectively immediately after bathing to trap moisture and restore the skin barrier 1, 2
• Replace all soaps and detergents with dispersible cream cleansers as soap substitutes to prevent stripping natural lipids 3, 1
• Regular bathing with lukewarm water for 5-10 minutes cleanses and hydrates the skin 1, 4

Trigger Avoidance

• Keep nails short to minimize trauma from scratching 3, 1
• Wear cotton clothing and avoid irritant fabrics such as wool next to the skin 3, 1
• Avoid extremes of temperature 3, 1

Patient Education

• Dedicate adequate time to explain topical corticosteroid potencies, benefits, and risks—patients' or parents' fears of steroids commonly lead to dangerous undertreatment 3, 1, 4
• Demonstrate proper application technique and provide written instructions 3, 1

Step 2: Topical Anti-Inflammatory Therapy

Topical Corticosteroids (First-Line)

• Apply topical corticosteroids no more than twice daily to affected areas, using the least potent preparation that controls symptoms 1, 5
• For facial eczema, use hydrocortisone 1-2.5% cream as the first-line low-potency option due to the high risk of atrophy on thin facial skin 1
• For body/extremity involvement, start with moderate-potency corticosteroids 4
• Very potent and potent corticosteroids should be used with caution for limited periods only, with short "steroid holidays" when possible 1
• Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is highest 1

Proactive Maintenance Therapy

• For patients with frequent recurrences or rapidly recurring localized sites after stopping treatment, continue application 2-3 times weekly of a mid-potency topical corticosteroid or tacrolimus to maintain control 5, 6

Alternative Topical Agents

• Topical calcineurin inhibitors (tacrolimus, pimecrolimus), crisaborole, and ruxolitinib cause no cutaneous atrophy and are options for reducing topical corticosteroid use, especially on sensitive sites 5, 6
• Delgocitinib ointment and difamilast ointment are additional topical anti-inflammatory options 6

Step 3: Managing Secondary Infections

Bacterial Infection Recognition

• Crusting, weeping, or pustules indicate secondary bacterial infection, most commonly Staphylococcus aureus 3, 1, 7
• Obtain bacteriological swabs if patients do not respond to initial treatment 3, 1

Bacterial Infection Treatment

• Flucloxacillin is the first-line oral antibiotic for S. aureus 1, 7
• For β-hemolytic streptococci, prescribe phenoxymethylpenicillin 7
• For penicillin allergy, use erythromycin 7
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not delay or withhold them 1, 7

Eczema Herpeticum (Medical Emergency)

• Grouped vesicles, punched-out erosions, or sudden deterioration with fever indicate possible eczema herpeticum 3, 1
• Initiate oral acyclovir early in the disease course 1, 7
• In febrile or systemically ill patients, administer acyclovir intravenously 1, 7
• Send swabs for virological screening and electron microscopy 3, 1

Step 4: Adjunctive Symptomatic Treatment

Pruritus Management

• Sedating antihistamines may help with nighttime itching through their sedative properties as a short-term adjuvant during relapses 3, 1
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used 1

Additional Topical Options

• Ichthammol (1% in zinc ointment) or coal tar solution (1% strength) can be useful for lichenified eczema, though ichthammol is less irritant than coal tar 3

Step 5: Systemic Therapy for Moderate-to-Severe Disease

When to Escalate

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks 1
• Quality of life significantly impacted despite optimized topical therapy 5
• Before advancing to systemic treatment, reevaluate to confirm diagnosis, manage comorbid conditions, address compliance and patient-specific concerns, and optimize topical therapy 5

First-Line Systemic Therapy

• Dupilumab (interleukin-4 receptor inhibitor) has become first-line systemic therapy given its efficacy and safety, allowing long-term treatment without laboratory monitoring 5, 2, 6

Alternative Systemic Options

• Other biologics: tralokinumab, nemolizumab 2, 6
• Janus kinase inhibitors: baricitinib, upadacitinib, abrocitinib 2, 6
• Conventional immunosuppressants: oral cyclosporine 6
• Phototherapy: narrow-band ultraviolet B (312 nm) or PUVA, though concern exists about long-term adverse effects such as premature skin aging and cutaneous malignancies 1

Systemic Corticosteroids (Limited Role)

• Systemic corticosteroids have a limited but definite role only for acute severe flares requiring rapid control when topical therapy has failed, for short-term "tiding over" during crisis periods 1
• Should not be used for maintenance treatment or to induce stable remission 1
• Pituitary-adrenal suppression and corticosteroid-related mortality are significant risks with prolonged use 1

Common Pitfalls to Avoid

• Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when possible 1
• Do not delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given 1, 7
• Do not use systemic antibiotics empirically for uninfected or colonized eczematous skin, as this increases bacterial resistance without improving outcomes 7
• Do not attempt house dust mite eradication—this is not currently recommended 3
• Dietary restriction is of little or no benefit in adults; in children, it is worth trying only in selected infants under professional supervision 3