First-Line Skin Cream Regimen for Atopic Dermatitis (Eczema)
Topical corticosteroids are the mainstay of treatment for eczema and should be used as first-line therapy, combined with liberal and frequent emollient application. 1
Core Treatment Strategy
Topical Corticosteroids (Primary Treatment)
Apply the least potent topical corticosteroid that controls your patient's eczema, using it once daily to affected areas. 2, 1 Twice-daily application has not been shown to be more effective than once-daily use. 3
For mild eczema on the body, start with hydrocortisone 1%, which does not cause systemic side effects when used appropriately. 2
For facial or thin-skinned areas (neck, flexures, genitals), use only low-potency preparations such as hydrocortisone 1-2.5% due to high risk of atrophy and telangiectasia. 1
For thicker, lichenified lesions on the body, you may need moderate-to-potent corticosteroids initially, but transition to lower potency once control is achieved. 4
Implement "steroid holidays" (short breaks) when the eczema is controlled to minimize side effects. 2, 1 Very potent and potent corticosteroids should be used with caution for limited periods only. 2, 1
Emollients (Essential Adjunctive Therapy)
Prescribe liberal emollient use as the cornerstone of maintenance therapy—this is not optional. 1, 5 Emollients reduce flare rates, decrease topical corticosteroid requirements, and improve disease severity. 6
Instruct patients to apply emollients immediately after bathing (within 3 minutes of patting skin dry) to trap moisture when skin is most hydrated. 4
Recommend at least twice-daily application, with more frequent use (3-4 times daily) for moderate-to-severe cases. 4
Ointments or thick creams are superior to lotions for eczema, as they provide better occlusion and barrier repair. 4 Fragrance-free formulations are essential. 4
For adults, expect to prescribe 200-400 grams per week when applying twice daily to affected areas. 4
Continue emollients even when eczema appears controlled—this prevents relapse and has documented steroid-sparing effects. 4, 1
Soap-Free Cleansing
Replace all soaps and detergents with dispersible creams or soap-free cleansers, as soaps remove natural lipid from the skin surface and worsen the underlying dry skin. 2, 1
Recommend lukewarm water only and limit bathing to 10-15 minutes to prevent excessive drying. 4
Addressing Common Pitfalls
Steroid Phobia
Patients' or parents' fears of steroids often lead to dangerous undertreatment. 2, 1 Explain clearly that:
- Different potencies exist for different body areas 2
- When used appropriately with breaks, topical corticosteroids are safe 2
- Undertreatment causes more harm than appropriate corticosteroid use 1
Recognizing Secondary Infection
Watch for crusting, weeping, or pustules—these indicate secondary bacterial infection with Staphylococcus aureus. 2, 1
When infection is present, prescribe oral flucloxacillin (or erythromycin if penicillin-allergic) while continuing topical corticosteroids concurrently—do not delay anti-inflammatory treatment. 2, 1
If you see grouped vesicles or punched-out erosions with sudden deterioration, suspect eczema herpeticum (medical emergency) and start oral acyclovir immediately. 2, 1
Antihistamines: Limited Role
Non-sedating antihistamines have little to no value in atopic eczema and should not be routinely prescribed. 2, 1, 5
Sedating antihistamines (hydroxyzine, diphenhydramine) may help nighttime itching through sedation, not direct antipruritic effects, and should be used only short-term during severe flares. 2, 1
Maintenance and Prevention
After achieving clearance, consider proactive maintenance therapy with topical corticosteroids applied twice weekly (weekend therapy) to previously affected sites to prevent relapse. 4
Aggressive emollient use must continue indefinitely, even when skin appears normal. 4, 1