How should chronic eczematous dermatitis be treated?

Treatment of Chronic Eczematous Dermatitis

Topical corticosteroids are the mainstay of treatment for chronic eczematous dermatitis and should be used as first-line therapy, combined with aggressive emollient use to restore the skin barrier. 1

First-Line Topical Corticosteroid Strategy

• Apply topical corticosteroids no more than twice daily to affected areas, using the least potent preparation that achieves symptom control. 1
• For facial involvement, use hydrocortisone 1–2.5% cream only, as facial skin is highly prone to steroid-induced atrophy and telangiectasia. 1
• For body and extremity lesions, select moderate-to-potent corticosteroids (e.g., prednicarbate 0.02%, mometasone furoate, or clobetasol propionate 0.05%) based on severity. 2, 1
• After achieving clearance (typically 2–4 weeks), transition to proactive maintenance: apply the same corticosteroid twice weekly to previously affected areas to prevent flares. 1
• Implement short "steroid holidays" when possible to minimize adverse effects such as skin atrophy, even on thicker-skinned areas. 1
• Never use medium- or high-potency steroids on the face—they cause unacceptable atrophy and telangiectasia. 3
• Limit continuous facial corticosteroid use to 2–4 weeks maximum; thereafter, use intermittent application or switch to alternative agents. 3, 1

Essential Emollient and Barrier Restoration

• Liberal emollient use is the cornerstone of maintenance therapy and must be applied regularly, even when eczema appears controlled. 1
• Apply fragrance-free emollients containing petrolatum, mineral oil, urea (≈10%), or glycerin immediately after bathing to damp skin (within 10–15 minutes) to create a surface lipid film that prevents transepidermal water loss. 3, 1
• Reapply emollients after each hand-wash and every 3–4 hours throughout the day. 3
• Substitute regular soaps with mild, pH-neutral (pH 5) non-soap cleansers or dispersible creams as soap substitutes, because soaps strip natural lipids and worsen barrier dysfunction. 3, 1
• Continue aggressive emollient use during clear periods for short- and long-term steroid-sparing benefits. 1

Products and Practices to Avoid

• Avoid all alcohol-containing preparations, especially on the face, as they significantly worsen dryness and trigger flares. 2, 3
• Do not use greasy or occlusive creams for basic care, as they facilitate folliculitis development due to their occlusive properties. 2, 3
• Avoid topical acne medications (especially retinoids), which irritate and worsen eczematous dermatitis due to their drying effects. 2, 3
• Do not use hot water for bathing; use tepid water instead to prevent worsening symptoms. 3
• Avoid harsh soaps, detergents, perfumes, and deodorants that strip natural skin lipids. 3
• Pat skin dry with clean towels rather than rubbing after bathing. 3

Alternative Topical Anti-Inflammatory Agents

• For patients requiring prolonged facial treatment beyond 4 weeks or when corticosteroid concerns exist, topical calcineurin inhibitors (pimecrolimus 1% cream or tacrolimus ointment) may be applied 2–3 times per week as proactive maintenance after disease stabilization. 1, 4
• Pimecrolimus is FDA-approved for adults and children ≥2 years old; use only for short periods with breaks in between, and stop when symptoms resolve. 4
• Do not use pimecrolimus in children under 2 years of age or in patients with weakened immune systems. 4
• The long-term safety of topical calcineurin inhibitors is not established; a very small number of users have developed cancer, though causality is unproven. 4

Management of Pruritus

• Sedating antihistamines (hydroxyzine, diphenhydramine, clemastine) may improve nighttime itching through their sedative properties, not direct antipruritic effects. 2, 1
• Oral H1-antihistamines such as cetirizine, loratadine, or fexofenadine may provide relief for grade 2/3 pruritus. 2
• Non-sedating antihistamines have no proven benefit in eczematous dermatitis and should not be routinely prescribed. 1
• Topical urea- or polidocanol-containing lotions can provide additional symptomatic relief for pruritus. 2, 3

Recognition and Treatment of Secondary Bacterial Infection

• Monitor for crusting, weeping, purulent exudate, or pustules—these indicate secondary infection with Staphylococcus aureus, the most common pathogen. 1
• When bacterial infection is confirmed, prescribe oral flucloxacillin (or erythromycin for penicillin allergy) while continuing topical corticosteroids concurrently—do not withhold steroids during appropriate antibiotic therapy. 1
• Obtain bacterial cultures when the skin fails to improve after initial antibiotic treatment to enable targeted antimicrobial selection. 1

Recognition and Treatment of Eczema Herpeticum (Medical Emergency)

• Suspect eczema herpeticum if grouped vesicles, punched-out erosions, or sudden deterioration with fever occur—this is a medical emergency. 1
• Initiate oral acyclovir immediately; in febrile or systemically ill patients, administer intravenous acyclovir. 1
• Early antiviral initiation is associated with shorter hospital stays and better clinical outcomes. 1

Adjunctive Measures

• Keep fingernails short to limit skin trauma from scratching and break the itch-scratch cycle. 3, 1
• Wear smooth cotton garments and avoid irritant fabrics such as wool. 1
• Maintain a cool ambient temperature and prevent excessive sweating, as heat and humidity are common triggers. 1
• Apply hypoallergenic sunscreen daily (at least SPF 30, UVA/UVB protection) with zinc oxide or titanium dioxide. 3
• Limit sun exposure during treatment; if outdoors, wear loose-fitting protective clothing. 4
• Do not use sun lamps, tanning beds, or ultraviolet light therapy during treatment with topical calcineurin inhibitors. 4

When to Refer or Escalate

• Refer patients who do not respond to moderate-to-potent topical corticosteroids after 4 weeks of appropriate use. 1
• Seek specialist management when systemic therapy (phototherapy, oral immunosuppressants, biologics) is contemplated. 1
• Promptly refer for emergency evaluation if eczema herpeticum is suspected. 1
• Consider dermatology referral for diagnostic uncertainty, atypical presentation, recurrent severe flares despite optimal maintenance therapy, or need for second-line treatments. 3

Common Pitfalls to Avoid

• Undertreatment due to fear of corticosteroid side effects is common—explain the different potencies and benefits/risks clearly to patients. 1
• Do not delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given. 1
• Avoid continuous daily use of very potent corticosteroids without breaks. 1
• Do not use systemic corticosteroids for maintenance treatment of chronic eczematous dermatitis—they have a limited role only for acute severe flares requiring rapid control after all other options are exhausted. 1, 5