What is the recommended management for eczema (atopic dermatitis) in an adult?

Management of Eczema (Atopic Dermatitis) in Adults

All adults with eczema should use daily moisturizers combined with topical corticosteroids for active lesions, with topical calcineurin inhibitors, JAK inhibitors, or PDE-4 inhibitors as steroid-sparing alternatives for maintenance therapy. 1

Foundation: Moisturizers as Essential Therapy

• Apply moisturizers liberally and frequently to all affected areas, regardless of disease severity, as they reduce inflammation, improve disease severity, and increase time between flares 1
• Use moisturizers as monotherapy only in very mild cases; otherwise combine with pharmacologic treatments 1
• Apply after bathing to minimize transepidermal water loss and improve stratum corneum hydration 1
• No specific moisturizer formulation can be recommended over another based on current evidence, so choose based on patient preference and tolerability 1
• Avoid moisturizers in jars (use tubes instead) to reduce contamination risk 2

First-Line Pharmacologic Treatment: Topical Corticosteroids

• Use medium to high-potency topical corticosteroids for acute flares on the body for 1-4 weeks 3
• Apply the least potent preparation that controls the dermatitis to minimize adverse effects 3
• For facial or genital lesions, use only low to mid-potency steroids (hydrocortisone 1% or triamcinolone 0.1%) to avoid skin atrophy and telangiectasia 2
• Never use high-potency steroids on the face, genitals, or intertriginous areas due to increased absorption and risk of atrophy 2
• Avoid long-term continuous use on any body site due to risks of skin thinning, telangiectasia, and tachyphylaxis 3

Steroid-Sparing Maintenance Options

The American Academy of Dermatology makes strong recommendations for three non-steroidal topical agents: 1

• Topical calcineurin inhibitors (TCIs): tacrolimus and pimecrolimus for maintenance therapy and sensitive areas 1
• Topical JAK inhibitors: newer agents with strong evidence for efficacy 1
• Topical PDE-4 inhibitors: crisaborole as an alternative anti-inflammatory option 1

These agents are particularly valuable for facial involvement, long-term maintenance, and proactive therapy to prevent flares 1

Adjunctive Measures with Conditional Support

• Bathing practices: Use soap-free cleansers and lukewarm water; evidence for specific bath additives (like dead sea salts) is minimal 1
• Wet wrap therapy: Consider for severe flares using the "soak and seal" method 3, 4
• Avoid topical antihistamines due to lack of efficacy and increased risk of contact dermatitis 1, 4
• Avoid routine topical antimicrobials or antiseptics in the absence of clinical infection 1

When to Suspect and Treat Secondary Complications

Bacterial superinfection (usually Staphylococcus aureus):

• Suspect when previously stable eczema suddenly worsens, or when crusting, weeping, or erosions appear 1, 4
• Obtain bacterial swabs and start empirical antibiotics (cephalexin or flucloxacillin) 4
• Consider bleach baths for patients with recurrent infections 5

Eczema herpeticum (herpes simplex superinfection):

• Suspect with grouped punched-out erosions or vesicles 4
• Perform Tzanck smear or viral culture and start urgent acyclovir 4

Contact dermatitis:

• Consider patch testing if the distribution is unusual, disease worsens with topical medications, or there is marked facial/eyelid involvement 2
• Note that 6-60% of atopic dermatitis patients have concomitant allergic contact dermatitis 2

Critical Pitfalls to Avoid

• Undertreatment: Use adequate potency and duration of topical corticosteroids based on severity and location 3
• Steroid phobia: Educate patients that appropriate short-term use is safe and necessary 3
• Missing allergen triggers: Evaluate for contact allergens in refractory cases, especially with new products (deodorants, detergents, jewelry) 2, 4
• Ignoring skin barrier repair: Moisturizers are not optional—they are foundational therapy 1
• Using topical antihistamines: These lack efficacy and increase sensitization risk 1, 4

Escalation for Moderate-to-Severe Disease

When topical therapies fail after appropriate optimization:

• Phototherapy (narrowband UVB) is the next step before systemic agents 3
• Consider systemic immunomodulators (cyclosporine, methotrexate, mycophenolate mofetil) for severe refractory cases 6, 7
• Dupilumab (biologic targeting IL-4/IL-13) is approved for moderate-to-severe atopic dermatitis in adults with rapid improvement in most patients 7

Monitoring and Follow-Up

• Reassess treatment response at each visit and adjust therapy accordingly 3
• If no improvement after 2 weeks of appropriate therapy, reconsider the diagnosis or evaluate for complicating factors (infection, contact dermatitis, non-adherence) 2
• Monitor for corticosteroid side effects with long-term use, particularly skin atrophy and telangiectasia 3
• Document disease severity and extent to track progress 3