What is the recommended stepwise management for a patient with eczema?

Stepwise Management of Eczema (Atopic Dermatitis)

First-Line Foundation: Emollients and Skin Barrier Restoration

Liberal emollient use is the cornerstone of eczema management and must be applied regularly—even when skin appears controlled—to restore the defective skin barrier that defines this disease. 1

• Apply emollients immediately after bathing to damp skin to create a surface lipid film that prevents transepidermal water loss 1, 2
• Prescribe adequate quantities: approximately 130 g/m²/week meets requirements for 95.8% of patients, though 600 g/week is recommended for adults 3, 4
• Not all emollients are equal: urea-glycerol containing moisturizers significantly strengthen skin barrier function and protect against irritants, whereas simple paraffin-based creams (the most commonly prescribed type in England) show no barrier improvement and may reduce natural moisturizing factors 3
• Use soap-free cleansers and avoid alcohol-containing products, as regular soaps strip natural lipids from already-dry eczematous skin 1

Step 1: Low-to-Moderate Potency Topical Corticosteroids

Start with low-to-medium potency topical corticosteroids (fluticasone, mometasone, or hydrocortisone 1-2.5%) applied once or twice daily to affected areas, using the least potent preparation that achieves control. 1, 2

• For mild eczema, hydrocortisone 1% is adequate and does not cause systemic absorption when used appropriately 2
• Apply no more than twice daily until lesions significantly improve 2
• Implement "steroid holidays"—short breaks from corticosteroids when possible—to minimize side effects including skin atrophy and tachyphylaxis 1, 2
• Critical precaution: Avoid potent or very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is highest; use only low-potency preparations (hydrocortisone 1-2.5%) in these locations 1, 2
• Address steroid phobia directly: 72.5% of patients worry about topical corticosteroids; explain that different potencies carry different risks and that undertreatment causes more harm than appropriate use 2

Step 2: Managing Pruritus

• Sedating antihistamines (hydroxyzine, diphenhydramine) may help nighttime itching through their sedative properties, not direct antipruritic effects 1
• Do not use non-sedating antihistamines—they have no value in atopic eczema and should be avoided 1

Step 3: Recognizing and Treating Secondary Infections

Do not delay or withhold topical corticosteroids when infection is present—continue them as primary treatment while adding appropriate systemic antibiotics concurrently. 1

Bacterial Infection (Most Common: Staphylococcus aureus)

• Watch for increased crusting, weeping, or pustules 1
• First-line antibiotic: Flucloxacillin orally 1
• Alternative for penicillin allergy or resistance: Erythromycin 1
• Continue topical corticosteroids during antibiotic treatment 1

Eczema Herpeticum (Medical Emergency)

• Suspect immediately if you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever 1
• Initiate oral acyclovir early in the disease course 1
• In ill, feverish patients, administer acyclovir intravenously 1
• This is a true dermatologic emergency requiring urgent treatment 1

Step 4: Proactive Maintenance Therapy

• For children with moderate-to-severe atopic dermatitis, apply fluticasone propionate or mometasone furoate twice weekly to previously affected areas for up to 16 weeks to prevent flares 2
• Continue liberal emollient use daily, which provides both short- and long-term steroid-sparing effects 2

Step 5: When to Refer or Escalate to Systemic Therapy

Refer to dermatology or consider escalation if:

• Failure to respond to moderate potency topical corticosteroids after 4 weeks 1, 2
• Need for systemic therapy or phototherapy 1, 2
• Suspected eczema herpeticum (immediate referral) 1
• Diagnostic uncertainty 2

Systemic Therapy Options (Severe Disease Only)

• Narrowband ultraviolet B (312 nm) phototherapy is an option for recalcitrant cases 1
• Systemic corticosteroids have a limited but definite role only for "tiding over" occasional patients during acute severe flares when topical therapy has failed—never for maintenance treatment 1
• Critical warning: Pituitary-adrenal suppression and corticosteroid-related mortality are significant risks with prolonged oral steroid use 1
• Consider cyclosporine A or mycophenolate mofetil for severe cases requiring systemic immunosuppression 5

Common Pitfalls to Avoid

• Undertreatment due to steroid phobia: Patients and parents often fear steroids, leading to inadequate control; explain potency differences clearly 1, 2
• Using very potent corticosteroids continuously without breaks: Always implement steroid holidays 1
• Prescribing insufficient emollient quantities: Most prescriptions fall short of the 600 g/week adult recommendation 3, 4
• Choosing simple paraffin-based emollients: These provide no barrier improvement; select urea-glycerol formulations instead 3
• Delaying corticosteroids during infection: Continue topical steroids with concurrent systemic antibiotics 1