What is the recommended treatment regimen for atopic eczema?

Evidence-Based Treatment Regimen for Atopic Eczema

First-Line Treatment: Topical Corticosteroids + Emollients

Apply topical corticosteroids twice daily to affected areas using the least potent preparation that controls symptoms, combined with liberal emollient use—this dual approach forms the cornerstone of eczema management. 1, 2

Topical Corticosteroid Selection by Body Site

• Face and periorbital areas: Use only low-potency preparations (hydrocortisone 1–2.5%) due to thin skin and high atrophy risk 1, 2
• Hands and body: Start with moderate-to-potent corticosteroids for active disease, then step down once controlled 3
• Avoid potent/very potent steroids on face, neck, flexures, and genitals where atrophy risk is highest 1

Application Protocol

• Apply no more than twice daily to eczematous areas only 1
• Implement "steroid holidays"—stop for short periods once symptoms improve to minimize pituitary-adrenal suppression 1, 2, 3
• Do not discontinue corticosteroids when infection is present—continue them while treating infection with appropriate systemic antibiotics 1, 3

Essential Emollient Therapy (Maintenance Backbone)

Apply emollients liberally and regularly to all skin, even when eczema appears controlled—this reduces flare rate by 60% and prolongs time to flare from 30 to 180 days. 3

Emollient Application Strategy

• Apply immediately after bathing to create a surface lipid film that prevents evaporative water loss 1, 2, 3
• Use soap-free cleansers (dispersible cream as soap substitute) instead of regular soap, which strips natural lipids 1, 2, 3
• Continue daily indefinitely as maintenance therapy 3
• If using moisturizers with topical corticosteroids, apply emollients after the steroid 1

Managing Secondary Bacterial Infection

Recognition

• Increased crusting, weeping, purulent exudate, or pustules indicate Staphylococcus aureus superinfection 1, 2, 3
• Grouped vesicles, punched-out erosions, or sudden deterioration with fever suggest eczema herpeticum—a medical emergency 1, 2, 3

Treatment Protocol

• First-line antibiotic: Oral flucloxacillin for S. aureus 1, 2, 3
• Penicillin allergy: Use erythromycin 1, 3
• Continue topical corticosteroids concurrently with systemic antibiotics—infection is not a contraindication 1, 2, 3
• Eczema herpeticum: Start oral acyclovir immediately; use IV acyclovir if febrile or systemically ill 1, 3

Managing Pruritus

• Sedating antihistamines (hydroxyzine, diphenhydramine) may help nighttime itching through sedative properties, not antipruritic effects—reserve for severe flares only 1, 2, 3
• Non-sedating antihistamines have no value in atopic eczema and should not be used 1, 2

Second-Line Therapies (When First-Line Fails After 4 Weeks)

Topical Calcineurin Inhibitors

• Pimecrolimus 1% cream or tacrolimus 0.1% ointment for steroid-sparing maintenance, particularly on face and sensitive areas 3, 4, 5
• Use only in patients ≥2 years old with non-weakened immune systems 4
• Apply for short periods with breaks in between; stop when symptoms resolve 4
• Do not use continuously long-term due to theoretical cancer risk (skin/lymphoma), though causal link unproven 4
• Avoid sun exposure, tanning beds, and UV therapy during treatment 4

Phototherapy

• Narrowband UVB (311 nm) is preferred for moderate-to-severe disease unresponsive to topical therapy 1, 5
• UVA1 wavelength is an alternative option 5
• Concern exists about long-term premature aging and cutaneous malignancies, particularly with PUVA 1

Systemic Therapy for Severe Refractory Disease

Dupilumab (Biologic)

• FDA-approved for moderate-to-severe atopic dermatitis in patients ≥6 months old whose disease is not adequately controlled with topical therapies 6
• Subcutaneous injection; can be used with or without topical corticosteroids 6
• Preferred systemic option given targeted mechanism and safety profile 7

Systemic Corticosteroids

• Limited role: Use only for acute severe flares requiring rapid control when topical therapy has failed, for short-term "tiding over" during crisis periods 1
• Never use for maintenance or stable remission 1
• Risk of pituitary-adrenal suppression and corticosteroid-related mortality 1

Other Immunosuppressives

• Cyclosporine A or mycophenolate mofetil for severe refractory cases 8, 5

Critical Pitfalls to Avoid

• Never delay topical corticosteroids due to infection—they remain primary treatment when appropriate antibiotics are given 1, 2, 3
• Do not undertreat due to steroid phobia—explain that appropriate short-term use of low-potency steroids is safer than chronic undertreated inflammation 2, 3
• Avoid continuous corticosteroid use—implement regular "steroid holidays" 1, 2, 3
• Do not use very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) 1, 2

When to Refer to Dermatology

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks of appropriate use 1, 2, 3
• Suspected eczema herpeticum (refer emergently) 1, 2, 3
• Need for systemic therapy or phototherapy 1, 3
• Diagnostic uncertainty distinguishing from contact dermatitis, tinea, or psoriasis 3